eMedicine Specialties > Psychiatry > Adult

Bulimia: Treatment & Medication

Author: Raj K Kalapatapu, MD, Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons
Coauthor(s): Kelda Harris Walsh, MD, Assistant Professor of Clinical Psychiatry, Section of Child and Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Chief, Obsessive-Compulsive/Tourette/Anxiety Disorders Clinic, Riley Hospital for Children; Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, MedStar Research Institute and Washington Hospital Center; Robert C Daly, MB, ChB, MPH, BCh, Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health
Contributor Information and Disclosures

Updated: Aug 12, 2008

Treatment

Medical Care

The proper management of bulimia is with a multidisciplinary approach. The minimum of care providers who should be involved in the care of these patients are the primary care provider, psychiatrist, psychotherapist, and a dietitian. Involvement of a psychotherapist with expertise in the management of eating disorders is strongly recommended. Dietary review and nutritional rehabilitation counseling should be provided by a nutritionist/registered dietitian. Depending on circumstances and complications, those with bulimia may also require the services of an endocrinologist or surgeon.

  • The goals of treatment are as follows:67
    • Reduce and, where possible, eliminate binge eating and purging
    • Treat physical complications
    • Enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment
    • Provide education regarding healthy nutrition and eating patterns
    • Help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to bulimia
    • Treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior
    • Enlist family support and provide family counseling and therapy where appropriate
    • Prevent relapse

Treatment should be comprehensive and multidisciplinary and may include the following components:67

  • Nutritional rehabilitation counseling: A structured meal plan is a means to reduce the episodes of dietary restriction and the urges to binge and purge. Adequate nutritional intake can prevent craving and promote satiety. Assessing nutritional intake for all patients, even those with a normal body weight (or normal BMI), is important because normal weight does not ensure appropriate nutritional intake or normal body composition. Among patients of normal weight, nutritional counseling is a useful part of treatment and helps reduce food restriction, increase the variety of foods eaten, and promote healthy but not compulsive exercise patterns.
  • Cognitive behavioral psychotherapy (CBT): Distorted or maladaptive cognitions regarding weight and shape are identified and addressed. Irrational beliefs are explored and confronted. Behavioral approaches to avoiding undesirable eating habits are used, including exposure to food. Cognitive distortions are examined to allow better understanding, enhanced self-control, and improved body image. The cognitive component of CBT appears to be the active ingredient for change, as behavioral interventions alone are not as effective.68,69
  • Interpersonal psychotherapy (IPT): Interpersonal psychotherapy works with specific issues in the interpersonal arena that create the context for the patient's symptoms; these fall within the categories of grief, role transition, role conflict, or interpersonal deficits. Brief focused therapy in these areas can be effective in producing improvements in those with mood disturbance and low self-esteem, which may trigger and maintain the symptoms of bulimia. Its efficacy is similar to CBT in reducing binge eating but may be somewhat less effective in curbing purging.
  • Family therapy: Family therapy explores family dynamics, dysfunctional relationships, and factors that may precipitate or perpetuate abnormal eating and bingeing behaviors. This technique often views eating as a means of communication within a family. Family therapy should be considered especially for adolescent patients still living with their parents or older patients with ongoing conflicted interactions with parents.
  • Psychodynamic psychotherapy: Using psychodynamic interventions in conjunction with CBT and other psychotherapies may yield better global outcomes. Some patients, particularly those with concurrent personality pathology or other co-occurring disorders, require lengthy treatment. Clinical reports suggest that psychodynamic and psychoanalytic approaches in individual or group format are useful once bingeing and purging improve.
  • Couples therapy: Patients with marital discord may benefit from couples therapy. Among people with bulimia in married or other cohabiting consensual adult relationships, the research is limited. Overall, these relationships are generally suggested to be suboptimal, with the appearance of impaired levels of intimacy in such relationships and suboptimal communication skills. Self-consciousness and self-silencing during sexual activity, and anxious attachment may be associated with bulimic symptoms.70 Counseling and openness about these problems may assist with the management of the bulimia.
  • Support and self-help groups: Support groups and 12-step programs such as Overeaters Anonymous may be helpful as adjuncts in the initial treatment of bulimia and for subsequent relapse prevention, but they are not recommended as the sole initial treatment approach for bulimia. In the most recent update of the Self-help and guided self-help for eating disorders in the Cochrane Database of Systematic Reviews,71 efficacies of pure self-help (PSH) and guided self-help (GSH) were mixed. PSH/GSH did not significantly differ from waiting list in abstinence from bingeing or purging, although PSH/GSH produced greater improvement on other eating disorder symptoms, psychiatric symptomatology and interpersonal functioning but not depression.
  • Supportive-expressive psychotherapy (SEP) or group therapy: SEP or group therapy may be helpful for patients with bulimia.
  • Bright light therapy has been shown to reduce binge frequency in several controlled trials and may be used as an adjunct when CBT and antidepressant therapy have not been effective in reducing bingeing symptoms.72
  • One study provided some support for guided imagery compared to journaling, although long-term maintenance of treatment effects is unknown.68 Dialectical behavior therapy and integrative cognitive-affective therapy may have an emerging role in treatment.73
  • Self-help support may also be available through books and online.
  • Pharmacotherapy: (see Medication)

Initial care may be on an inpatient or outpatient basis, depending on the clinical presentation. Factors that may indicate a need for inpatient care include significant metabolic abnormalities, medical complications, risk of suicide, failed outpatient treatment, inability to care for self, and diagnostic uncertainty.

  • Inpatient care for the patient with bulimia should be considered when any of the following are present, alone or in combination:67
    • Diagnostic uncertainty
    • Associated secondary infections
    • Medical comorbidities (eg, arrhythmias, significant electrolyte derangements, dehydration, organ compromise requiring acute treatment)
    • Suicidality with specific plan with high lethality or intent
    • Absence of a support structure at home
    • Severe impairments in the patient's capacity to function in regular daily activities (ie, severe psychosocial impairment)
    • Failed outpatient treatment
    • Significant concerns over follow-up (whether patient or program related)
    • Any existing psychiatric disorder that would require hospitalization

Surgical Care

Major medical treatment requiring surgical intervention is rare, but medical care providers should be familiar with potential serious complications.

  • Patients may develop an acute gastric obstruction and/or gastric dilatation74 (possibly resulting in gastric perforation leading to acute peritonitis), which presents with severe, continuous projectile vomiting that occurs soon after any oral intake. This should be considered in individuals with known bulimia who present complaining of uncontrollable vomiting. Consumption of nonfood material during binges or soon after should be considered, as well.
    • When the potential for gastric dilatation, outlet obstruction, or both is considered, an urgent surgical consultation is indicated for possible surgical management.
    • These conditions are surgical emergencies and, although uncommon, are the major cause of bulimia-related mortality.
  • Emergency surgical review is also required if symptoms suggestive of esophageal tear (Mallory-Weiss syndrome) develop or in case of esophageal rupture, which can precipitate acute mediastinitis. (See Media files 2-9). For more information, see eMedicine articles Mallory-Weiss Syndrome and Esophageal Rupture.

Consultations

Dental professionals can play a unique role in opening a dialogue with patients about eating disorders. They can help with early recognition and refer patients to professionals specializing in the evaluation and treatment of eating disorders. The dental professional can become an important contributor to the recovery and long-term treatment of the patient with an eating disorder.56,75

Diet

As the disorder is treated, patient education regarding balanced diets, exercise, and long-term maintenance of a healthy weight is important and may reduce the risk of relapse or development of chronic symptoms.

Medication

  • Antidepressants as a group are the mainstay of pharmacotherapy.67 These may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms or for patients who have not benefited from or had only a suboptimal response to appropriate psychosocial therapy.
  • Selective serotonin reuptake inhibitors (SSRIs) have the most evidence for efficacy and the fewest difficulties with adverse side effects.76,67 Only fluoxetine (Prozac) is approved by the Food and Drug Administration (FDA) for treatment of bulimia. Sertraline is the only other SSRI that has been shown to be effective, as demonstrated in a small, randomized controlled trial. Fluvoxamine77 and citalopram78 have also shown benefit. The exact mechanism underlying the efficacy of antidepressants in bulimia is unclear, but the effects may be mediated through their salutary impact on cerebral serotonin systems.
  • Bupropion (Wellbutrin) is relatively contraindicated in the treatment of bulimia nervosa because of a higher risk of seizures induced by the medication.67
  • Tricyclic antidepressants79 and monoamine oxidase inhibitors (MAOIs) have been used in patients with bulimia, although rarely, but are not recommended as initial treatments.67
  • Small controlled trials have demonstrated efficacy of the anticonvulsant topiramate, but because adverse reactions to this medication are common, it should be used only when other medications have proven ineffective. Also, because patients tend to lose weight on topiramate, its use is problematic for normal or underweight patients.67,80
  • Lithium and valproic acid, both mood stabilizers, are prone to induce weight gain in patients and may be less acceptable to patients who are weight preoccupied. Lithium is not recommended for patients with bulimia because it is ineffective. In patients with co-occurring bipolar disorder and bulimia nervosa, treatment with lithium is more likely to be associated with toxicity.67,81
  • Reports suggest the use of ondansetron,82 baclofen,83 and an antiandrogenic oral contraceptive84 as alternative pharmacotherapeutic options in the management of bulimia nervosa. Trials investigating naltrexone (ReVia) and venlafaxine have shown no significant benefit.
  • Clinicians must be aware of the black box warnings relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families if such medications are to be prescribed. See the statement on Antidepressant Use in Children, Adolescents, and Adults by the Food and Drug Administration.
  • Case reports indicate that methylphenidate may be helpful for patients with bulimia nervosa and concurrent ADHD. Methylphenidate should be used only for patients who have a very clear diagnosis of ADHD.67
  • The most recent update of Antidepressants versus placebo for people with bulimia nervosa in the Cochrane Database of Systematic Reviews included tricyclic antidepressants (TCAs), SSRIs, MAOIs, and other classes of drugs (mianserin, trazodone, bupropion). Similar results were obtained in terms of efficacy for these different groups of drugs. Patients with TCAs depressed out due to any cause more frequently than patients with placebo, and the opposite was found for fluoxetine.85

Antidepressants

SSRIs are the most commonly prescribed medications. Doses are higher than those typically used for depression management.


Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal effect in the reuptake of norepinephrine or dopamine. The antidepressant, anti-obsessive-compulsive, and antibulimic actions are presumed to be linked to inhibition of CNS neuronal uptake of serotonin. Efficacy was demonstrated in two 8-wk and one 16-wk multicenter parallel group studies of adult outpatients meeting DSM-III-R criteria for bulimia. Patients in the 8-wk studies received either 20 mg/d or 60 mg/d of fluoxetine or placebo in the morning. Patients in the 16-wk study received a fixed fluoxetine dose of 60 mg/d or placebo. Patients in these 3 studies had moderate-to-severe bulimia with median binge eating and vomiting frequencies ranging from 7-10 episodes per wk and 5-9 episodes per wk, respectively. Fluoxetine 60 mg (but not 20 mg) was superior to placebo in reducing the number of binge-eating and vomiting episodes per wk.

Adult

60-80 mg PO qd

Pediatric

Not established

Increases toxicity of diazepam, alprazolam, midazolam, flecainide, vinblastine, TCAs, and trazodone by decreasing clearance; also increases toxicity of MAOIs, haloperidol, clozapine, phenytoin, carbamazepine, and highly protein-bound drugs (eg, warfarin, digoxin); monitor lithium levels (levels reported to increase or decrease with concurrent use)

Documented hypersensitivity; current use of MAOIs or use within previous 2 wk

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy; adverse effects include anxiety, nervousness, insomnia, mania/hypomania, and anorexia


Desipramine (Norpramin)

Secondary-amine tricyclic that may increase synaptic concentration of norepinephrine in CNS by inhibiting reuptake by presynaptic neuronal membrane. May have effects in the desensitization of adenyl cyclase, down-regulation of beta-adrenergic receptors, and down-regulation of serotonin receptors.

Adult

100-300 mg PO qd

Pediatric

Not established

Decreases antihypertensive effects of clonidine and guanethidine but increases effects of sympathomimetics, cimetidine, and benzodiazepines; effects of desipramine increase with phenytoin, phenothiazines, carbamazepine, and barbiturates

Documented hypersensitivity; narrow-angle glaucoma, recent postmyocardial infarction; current use of MAOIs or fluoxetine or use within previous 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, glaucoma, hyperthyroidism, and thyroid replacement therapy; may impair mental and/or physical abilities


Amitriptyline (Elavil)

Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May increase or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity.

Adult

25-150 mg PO qd

Pediatric

Not established

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme (debrisoquin hydroxylase) system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, SSRIs, alcohol, CNS depressants, barbiturates, and disulfiram; if given with anticholinergic agents or sympathomimetic drugs, including epinephrine combined with local anesthetics, close supervision and careful adjustment of dosages is required; hyperpyrexia reported with concurrent use of anticholinergic agents or with neuroleptic drugs, particularly during hot weather; caution if patients receive large doses of ethchlorvynol concurrently (transient delirium has been reported)

Documented hypersensitivity; MAOIs in past 14 d; acute phase after MI; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, seizures, urinary retention, angle-closure glaucoma or increased intraocular pressure, and hepatic or renal impairment; avoid using in elderly persons


Imipramine (Tofranil)

Dibenzazepine antidepressant, referred to as a tricyclic because of its chemical structure. Metabolized to desipramine, which is marketed separately.
Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neuron.
Use parenteral administration for starting therapy only in patients unable or unwilling to use oral medication.
Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa.

Adult

25 mg PO tid initially and increase 25-50 mg at weekly intervals prn to 200 mg/d; not to exceed 300 mg/d

Pediatric

<6 years: Not established
6-12 years: 10-30 mg/d PO or 1-5 mg/kg/d PO in divided doses
>12 years: Administer as in adults

Increases toxicity of sympathomimetic agents such as isoproterenol and epinephrine by potentiating effects and inhibiting antihypertensive effects of clonidine; coadministration with or use within 2 wk of MAOIs or fluoxetine may cause serotonin syndrome or hypertensive crisis

Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following myocardial infarction; current use of MAOIs or fluoxetine or use within previous 2 wk

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May impair mental or physical abilities required for performance of potentially hazardous tasks including handling machinery, driving; caution in cardiovascular disease, conduction disturbances, seizure disorders, asthma, mental illness, Parkinson disease, increased intraocular pressure or angle-closure glaucoma, benign prostatic hypertrophy, GI disease, gastroesophageal reflux disease (GERD), urinary retention, hyperthyroidism, or receiving thyroid replacement; can induce or exacerbate hiatal hernia, and can cause paralytic ileus or constipation; anticholinergic effects may increase lens discomfort (eg, mydriasis, disturbance of accommodation, dry eyes) for contact lens wearers; avoid abrupt discontinuation (may cause nausea, vomiting, or diarrhea); agranulocytosis, thrombocytopenia, eosinophilia, leukopenia, and purpura reported; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment

More on Bulimia

Overview: Bulimia
Differential Diagnoses & Workup: Bulimia
Treatment & Medication: Bulimia
Follow-up: Bulimia
Multimedia: Bulimia
References
Further Reading
[ CLOSE WINDOW ]

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. In: American Psychiatric Association. 4th ed. Washington, DC; 2000.

  2. Santonastaso P, Zanetti T, De Antoni C, Tenconi E, Favaro A. Anorexia nervosa patients with a prior history of bulimia nervosa. Comprehensive Psychiatry. November-December 2006;47(6):519-522. [Medline].

  3. Button E, Aldridge S. Season of birth and eating disorders: patterns across diagnoses in a specialized eating disorders service. International Journal of Eating Disorders. July 2007;40(5):468-471. [Medline]. [Full Text].

  4. Morgan JF, Lacey JH. Season of birth and bulimia nervosa. International Journal of Eating Disorders. May 2000;27(4):452-458. [Medline]. [Full Text].

  5. Poyastro Pinheiro A, Thornton LM, Plotonicov KH, Tozzi F, Klump KL, Berrettini WH, et al. Patterns of menstrual disturbance in eating disorders. International Journal of Eating Disorders. July 2007;40(5):424-434. [Medline]. [Full Text].

  6. Ribasés M, Fernández-Aranda F, Gratacòs M, Mercader JM, Casasnovas C, Núñez A, et al. Contribution of the serotoninergic system to anxious and depressive traits that may be partially responsible for the phenotypical variability of bulimia nervosa. Journal of Psychiatric Research. January 2008;42(1):50-57. [Medline].

  7. Monteleone P, Tortorella A, Martiadis V, Serino I, Di Filippo C, Maj M. Association between A218C polymorphism of the tryptophan-hydroxylase-1 gene, harm avoidance and binge eating behavior in bulimia nervosa. Neuroscience Letters. June 21, 2007;421(1):42-46. [Medline].

  8. Monteleone P, Santonastaso P, Mauri M, Bellodi L, Erzegovesi S, Fuschino A, et al. Investigation of the serotonin transporter regulatory region polymorphism in bulimia nervosa: relationships to harm avoidance, nutritional parameters, and psychiatric comorbidity. Psychosomatic Medicine. Jan-Feb 2006;68(1):99-103. [Medline]. [Full Text].

  9. Fetissov SO, Harro J, Jaanisk M, Järv A, Podar I, Allik J, et al. Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. Proceedings of the National Academy of Sciences of the United States of America. October 11, 2005;102(41):14865-14870. [Medline]. [Full Text].

  10. Bacanu SA, Bulik CM, Klump KL, Fichter MM, Halmi KA, Keel P, et al. Linkage analysis of anorexia and bulimia nervosa cohorts using selected behavioral phenotypes as quantitative traits or covariates. American Journal of Medical Genetics Part B (Neuropsychiatric Genetics). November 5, 2005;139(1):61-68. [Medline]. [Full Text].

  11. Steiger H, Bruce KR. Phenotypes, endophenotypes, and genotypes in bulimia spectrum eating disorders. Canadian Journal of Psychiatry. April 2007;52(4):220-227. [Medline].

  12. Monteleone P, Zanardini R, Tortorella A, Gennarelli M, Castaldo E, Canestrelli B, et al. The 196G/A (val66met) polymorphism of the BDNF gene is significantly associated with binge eating behavior in women with bulimia nervosa or binge eating disorder. Neuroscience Letters. October 2, 2006;406(1-2):133-137. [Medline].

  13. Mercader JM, Ribasés M, Gratacòs M, González JR, Bayés M, de Cid R, et al. Altered brain-derived neurotrophic factor blood levels and gene variability are associated with anorexia and bulimia. Genes, Brain, and Behavior. November 2007;6(8):706-716. [Medline]. [Full Text].

  14. Torsello A, Brambilla F, Tamiazzo L, Bulgarelli I, Rapetti D, Bresciani E, et al. Central dysregulations in the control of energy homeostasis and endocrine alterations in anorexia and bulimia nervosa. Journal of Endocrinological Investigation. December 2007;30(11):962-976. [Medline].

  15. Miyasaka K, Hosoya H, Sekime A, Ohta M, Amono H, Matsushita S, et al. Association of ghrelin receptor gene polymorphism with bulimia nervosa in a Japanese population. Journal of Neural Transmission. September 2006;113(9):1279-1285. [Medline]. [Full Text].

  16. Monteleone P, Tortorella A, Castaldo E, Di Filippo C, Maj M. No association of the Arg51Gln and Leu72Met polymorphisms of the ghrelin gene with anorexia nervosa or bulimia nervosa. Neuroscience Letters. May 8, 2006;398(3):325-327. [Medline].

  17. Ando T, Komaki G, Naruo T, Okabe K, Takii M, Kawai K, et al. Possible role of preproghrelin gene polymorphisms in susceptibility to bulimia nervosa. American Journal of Medical Genetics part B (Neuropsychiatric Genetics). December 5, 2006;141(8):929-934. [Medline]. [Full Text].

  18. Uher R, Treasure J. Brain lesions and eating disorders. Journal of Neurology, Neurosurgery, and Psychiatry. June 2005;76(6):852-857. [Medline]. [Full Text].

  19. Frank GK, Bailer UF, Meltzer CC, Price JC, Mathis CA, Wagner A, et al. Regional cerebral blood flow after recovery from anorexia or bulimia nervosa. International Journal of Eating Disorders. September 2007;40(6):488-492. [Medline]. [Full Text].

  20. Goldfield GS, Blouin AG, Woodside DB. Body image, binge eating, and bulimia nervosa in male bodybuilders. Canadian Journal of Psychiatry. March 2006;51(3):160-168. [Medline].

  21. Johnson MD. Disordered eating in active and athletic women. Clin Sports Med. Apr 1994;13(2):355-69. [Medline].

  22. Leon GR. Eating disorders in female athletes. Sports Med. Oct 1991;12(4):219-27. [Medline].

  23. Ravaldi C, Vannacci A, Bolognesi E, Mancini S, Faravelli C, Ricca V. Gender role, eating disorder symptoms, and body image concern in ballet dancers. Journal of Psychosomatic Research. October 2006;61(4):529-535. [Medline].

  24. Perez M, Hernandez A, Clarke A, Joiner TE Jr. Analysis of bulimic symptomatology across age and geographic locations. Eating Behaviors. January 2007;8(1):136-142. [Medline].

  25. Chui W, Safer DL, Bryson SW, Agras WS, Wilson GT. A comparison of ethnic groups in the treatment of bulimia nervosa. Eating Behaviors. 2007;8:485-491. [Medline].

  26. Franko DL, Becker AE, Thomas JJ, Herzog DB. Cross-ethnic differences in eating disorder symptoms and related distress. International Journal of Eating Disorders. March 2007;40(2):156-164. [Medline]. [Full Text].

  27. Hrabosky JI, Grilo CM. Body image and eating disordered behavior in a community sample of Black and Hispanic women. Eating Behaviors. January 2007;8(1):106-114. [Medline].

  28. Mancilla-Diaz JM, Franco-Paredes K, Vazquez-Arevalo R, Lopez-Aguilar X, Alvarez-Rayon GL, Tellez-Giron MT. A two-stage epidemiologic study on prevalence of eating disorders in female university students in Mexico. European Eating Disorders Review. November 2007;15(6):463-470. [Medline]. [Full Text].

  29. Soh N, Surgenor LJ, Touyz S, Walter G. Eating disorders across two cultures: does the expression of psychological control vary?. The Australian and New Zealand Journal of Psychiatry. April 2007;41(4):351-358. [Medline].

  30. Tseng MM, Fang D, Lee MB, Chie WC, Liu JP, Chen WJ. Two-phase survey of eating disorders in gifted dance and non-dance high-school students in Taiwan. Psychological Medicine. August 2007;37(8):1085-1096. [Medline].

  31. Morgan CD, Marsh C. Bulimia nervosa in an elderly male: a case report. International Journal of Eating Disorders. March 2006;39(2):170-171. [Medline]. [Full Text].

  32. Ruiz MC, Soler-Gonzalez J. Images in clinical medicine. Unfortunate ingestion. New England Journal of Medicine. November 24, 2005;353:2270. [Medline]. [Full Text].

  33. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. Dec 4 1999;319(7223):1467-8. [Medline].

  34. Cotton MA, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. Jan 2003;18(1):53-6. [Medline].

  35. Mintz LB, O''Halloran MS. The Eating Attitudes Test: validation with DSM-IV eating disorder criteria. J Pers Assess. Jun 2000;74(3):489-503. [Medline].

  36. Keery H, Boutelle K, van den Berg P, Thompson JK. The impact of appearance-related teasing by family members. Journal of Adolescent Health. August 2005;37(2):120-127. [Medline].

  37. Godart NT, Perdereau F, Rein Z, Berthoz S, Wallier J, Jeammet P, et al. Comorbidity studies of eating disorders and mood disorders. Critical review of the literature. Journal of Affective Disorders. January 2007;97(1-3):37-49. [Medline].

  38. Mazzeo SE, Slof-Op't Landt MC, Jones I, Mitchell K, Kendler KS, Neale MC, et al. Associations among postpartum depression, eating disorders, and perfectionism in a population-based sample of adult women. Internation Journal of Eating Disorders. April 2006;39(3):202-211. [Medline]. [Full Text].

  39. Duncan AE, Neuman RJ, Kramer JR, Kuperman S, Hesselbrock VM, Bucholz KK. Lifetime psychiatric comorbidity of alcohol dependence and bulimia nervosa in women. Drug and Alcohol Dependence. September 1, 2006;84(1):122-132. [Medline].

  40. Luce KH, Engler PA, Crowther JH. Eating disorders and alcohol use: group differences in consumption rates and drinking motives. Eating Behaviors. April 2007;8(2):177-184. [Medline].

  41. Anzengruber D, Klump KL, Thornton L, Brandt H, Crawford S, Fichter MM, et al. Smoking in eating disorders. Eating Behaviors. November 2006;7(4):291-299. [Medline].

  42. Baker JH, Mazzeo SE, Kendler KS. Association between broadly defined bulimia nervosa and drug use disorders: common genetic and environmental influences. International Journal of Eating Disorders. December 2007;40(8):673-678. [Medline]. [Full Text].

  43. Striegel-Moore RH, Franko DL, Thompson D, Barton B, Schreiber GB, Daniels SR. Caffeine intake in eating disorders. International Journal of Eating Disorders. March 2006;39(2):162-165. [Medline]. [Full Text].

  44. Fernández-Aranda F, Jiménez-Murcia S, Alvarez-Moya EM, Granero R, Vallejo J, Bulik CM. Impulse control disorders in eating disorders: clinical and therapeutic implications. Comprehensive Psychiatry. November-December 2006;47(6):482-488. [Medline].

  45. Fedorowicz VJ, Falissard B, Foulon C, Dardennes R, Divac SM, Guelfi JD, et al. Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders. International Journal of Eating Disorders. November 2007;40(7):589-595. [Medline]. [Full Text].

  46. Feldman MB, Meyer IH. Childhood abuse and eating disorders in gay and bisexual men. International Journal of Eating Disorders. July 2007;40(5):418-423. [Medline]. [Full Text].

  47. Wonderlich SA, Rosenfeldt S, Crosby RD, Mitchell JE, Engel SG, Smyth J, et al. The effects of childhood trauma on daily mood lability and comorbid psychopathology in bulimia nervosa. Journal of Traumatic Stress. February 2007;20(1):77-87. [Medline]. [Full Text].

  48. Zeeck A, Birindelli E, Sandholz A, Joos A, Herzog T, Hartmann A. Symptom severity and treatment course of bulimic patients with and without a borderline personality disorder. European Eating Disorders Review. November 2007;15(6):430-438. [Medline]. [Full Text].

  49. Lehoux PM, Howe N. Perceived non-shared environment, personality traits, family factors and developmental experiences in bulimia nervosa. British Journal of Clinical Psychology. March 2007;46 (Part 1):47-66. [Medline].

  50. Waller G, Sines J, Meyer C, Foster E, Skelton A. Narcissism and narcissistic defences in the eating disorders. International Journal of Eating Disorders. March 2007;40(2):143-148. [Medline]. [Full Text].

  51. Stein KF, Corte C. Identity impairment and the eating disorders: content and organization of the self-concept in women with anorexia nervosa and bulimia nervosa. European Eating Disorders Review. January 2007;15(1):58-69. [Medline]. [Full Text].

  52. Surman CB, Randall ET, Biederman J. Association between attention-deficit/hyperactivity disorder and bulimia nervosa: analysis of 4 case-control studies. Journal of Clinical Psychiatry. March 2006;67(3):351-354. [Medline]. [Full Text].

  53. Mandel L, Abai S. Diagnosing bulimia nervosa with parotid gland swelling. The Journal of the American Dental Association. May 2004;135:613-616. [Medline]. [Full Text].

  54. Mandel L, Kaynar A. Bulimia and parotid swelling: a review and case report. J Oral Maxillofac Surg. Oct 1992;50(10):1122-5. [Medline].

  55. Vavrina J, Müller W, Gebbers JO. Enlargement of salivary glands in bulimia. The Journal of Laryngology & Otology. June 1994;108:516-518. [Medline].

  56. Burkhart N, Roberts M, Alexander M, Dodds A. Communicating effectively with patients suspected of having bulimia nervosa. The Journal of the American Dental Association. August 2005;136(8):1130-1137. [Medline]. [Full Text].

  57. Kavoura V, Kourtis SG, Zoidis P, Andritsakis DP, Doukoudakis A. Full-mouth rehabilitation of a patient with bulimia nervosa. A case report. Quintessence International. July-August 2005;36(7-8):501-510. [Medline].

  58. Zachariasen RD. Oral signs and symptoms of bulimia nervosa. J Gt Houst Dent Soc. Aug 1997;69(1):31-4. [Medline].

  59. Glorio R, Allevato M, De Pablo A, Abbruzzese M, Carmona L, Savarin M, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. International Journal of Dermatology. May 2000;39:348-353. [Medline]. [Full Text].

  60. Daluiski A, Rahbar B, Meals RA. Russell''s sign. Subtle hand changes in patients with bulimia nervosa. Clin Orthop. Oct 1997;(343):107-9. [Medline].

  61. Strumia R. Dermatologic signs in patients with eating disorders. American Journal of Clinical Dermatology. 2005;6(3):165-173. [Medline].

  62. Mitchell JE, Crow S. Medical complications of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry. July 2006;19(4):438-443. [Medline].

  63. Sadock, B.J., and Sadock, V.A. Eating Disorders. In: Grebb, J.A., Pataki, C.S., and Sussman, N. Synopsis of Psychiatry. 10th Edition. Lippincott, Williams, & Wilkins; 2007:Chapter 23.

  64. Kruger D. Bulimia nervosa: easy to hide but essential to recognize. Journal of the American Academy of Physician Assistants. January 2008;21(1):48-52. [Medline].

  65. Bosanac P, Kurlender S, Stojanovska L, Hallam K, Norman T, McGrath C, et al. Neuropsychological study of underweight and "weight-recovered" anorexia nervosa compared with bulimia nervosa and normal controls. International Journal of Eating Disorders. November 2007;40(7):613-621. [Medline]. [Full Text].

  66. Brand M, Franke-Sievert C, Jacoby GE, Markowitsch HJ, Tuschen-Caffier B. Neuropsychological correlates of decision making in patients with bulimia nervosa. Neuropsychology. November 2007;21(6):742-750. [Medline].

  67. American Psychiatric Association. Treatment of patients with eating disorders, third edition. American Journal of Psychiatry. July 2006;163 (7 supplement):4-54. [Medline]. [Full Text].

  68. Berkman ND, Bulik CM, Brownley KA, Lohr KN, Sedway JA, Rooks A, et al. Management of eating disorders. Evidence Report/Technology Assessment. April 2006;135:1-166. [Medline]. [Full Text].

  69. Shapiro JR, Berkman ND, Brownley KA, Sedway JA, Lohr KN, Bulik CM. Bulimia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders. May 2007;40(4):321-336. [Medline]. [Full Text].

  70. Schembri C, Evans L. Adverse relationship processes: the attempts of women with bulimia nervosa symptoms to fit the perceived ideal of intimate partners. European Eating Disorders Review. January 2008;16(1):59-66. [Medline]. [Full Text].

  71. Self-help and guided self-help for eating disorders, Volume 4 [database online]. The Cochrane Database of Systematic Reviews: The Cochrane Library, The Cochrane Collaboration; 2002. Updated 2007.

  72. American Psychiatric Association. Treatment of Patients with Eating Disorders, Third Edition. American Journal of Psychiatry. July 2006;163 (7 Suppl):4-54. [Medline]. [Full Text].

  73. Mitchell JE, Agras S, Wonderlich S. Treatment of bulimia nervosa: where are we and where are we going?. International Journal of Eating Disorders. March 2007;40(2):95-101. [Medline]. [Full Text].

  74. Adson DE, Mitchell JE, Trenkner SW. The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature. Int J Eat Disord. Mar 1997;21(2):103-14. [Medline].

  75. DeBate RD, Shuman D, Tedesco LA. Eating disorders in the oral health curriculum. Journal of Dental Education. May 2007;71(5):655-663. [Medline]. [Full Text].

  76. Mayer LE, Walsh BT. The use of selective serotonin reuptake inhibitors in eating disorders. J Clin Psychiatry. 1998;59 Suppl 15:28-34. [Medline].

  77. Milano W, Siano C, Putrella C, Capasso A. Treatment of bulimia nervosa with fluvoxamine: a randomized controlled trial. Advances in Therapy. May-June 2005;22(3):278-283. [Medline].

  78. Leombruni P, Amianto F, Delsedime N, Gramaglia C, Abbate-Daga G, Fassino S. Citalopram versus fluoxetine for the treatment of patients with bulimia nervosa: a single-blind randomized controlled trial. Advances in Therapy. May-June 2006;23(3):481-494. [Medline].

  79. Walsh BT, Sysko R, Parides MK. Early response to desipramine among women with bulimia nervosa. International Journal of Eating Disorders. January 2006;39(1):72-75. [Medline]. [Full Text].

  80. McElroy SL, Arnold LM, Shapira NA, et al. Topiramate in the treatment of binge eating disorder associated with obesity: a randomized, placebo-controlled trial. Am J Psychiatry. Feb 2003;160(2):255-61. [Medline].

  81. Hsu LK, Clement L, Santhouse R, Ju ES. Treatment of bulimia nervosa with lithium carbonate. A controlled study. J Nerv Ment Dis. Jun 1991;179(6):351-5. [Medline].

  82. Faris PL, Kim SW, Meller WH, et al. Effect of decreasing afferent vagal activity with ondansetron on symptoms of bulimia nervosa: a randomised, double-blind trial. Lancet. Mar 4 2000;355(9206):792-7. [Medline].

  83. Broft AI, Spanos A, Corwin RL, Mayer L, Steinglass J, Devlin MJ, et al. Baclofen for binge eating: an open-label trial. International Journal of Eating Disorders. December 2007;40(8):687-691. [Medline]. [Full Text].

  84. Naessén S, Carlström K, Byström B, Pierre Y, Hirschberg AL. Effects of an antiandrogenic oral contraceptive on appetite and eating behavior in bulimic women. Psychoneuroendocrinology. June 2007;32(5):548-554. [Medline].

  85. Antidepressants versus placebo for people with bulimia nervosa, Volume 1 [database online]. The Cochrane Database of Systematic Reviews: The Cochrane Library, The Cochrane Collaboration; 1999. Updated 2002.

  86. Psychotherapy for bulimia nervosa and binging, Volume 1 [database online]. The Cochrane Database of Systematic Reviews: The Cochrane Library, The Cochrane Collaboration; 1998. Updated 2005.

  87. Antidepressants versus psychological treatments and their combination for bulimia nervosa [database online]. The Cochrane Database of Systematic Reviews: The Cochrane Library, The Cochrane Collaboration; 1997. Updated 2005.

  88. Grunwald M, Wesemann D. Special online consulting for patients with eating disorders and their relatives: analysis of user characteristics and E-mail content. Cyberpsychology & Behavior. February 2007;10:57-63. [Medline]. [Full Text].

  89. Jacobi C, Morris L, Beckers C, Bronisch-Holtze J, Winter J, Winzelberg AJ, et al. Maintenance of internet-based prevention: a randomized controlled trial. International Journal of Eating Disorders. March 2007;40:114-119. [Medline]. [Full Text].

  90. Ljotsson B, Lundin C, Mitsell K, Carlbring P, Ramklint M, Ghaderi A. Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy. Behaviour Research and Therapy. April 2007;45:649-661. [Medline].

  91. Robinson S, Perkins S, Bauer S, Hammond N, Treasure J, Schmidt U. Aftercare intervention through text messaging in the treatment of bulimia nervosa--feasibility pilot. International Journal of Eating Disorders. December 2006;39:633-638. [Medline]. [Full Text].

  92. Fichter MM, Quadflieg N. Long-term stability of eating disorder diagnoses. International Journal of Eating Disorders. November 2007;40 Supplement:S61-S66. [Medline]. [Full Text].

  93. Milos G, Spindler A, Schnyder U, Fairburn CG. Instability of eating disorder diagnoses: prospective study. British Journal of Psychiatry. December 2005;187:573-578. [Medline]. [Full Text].

  94. Grilo CM, Pagano ME, Skodol AE, Sanislow CA, McGlashan TH, Gunderson JG, et al. Natural course of bulimia nervosa and of eating disorder not otherwise specified: 5-year prospective study of remissions, relapses, and the effects of personality disorder psychopathology. Journal of Clinical Psychiatry. May 2007;68(5):738-746. [Medline]. [Full Text].

  95. Björck C, Clinton D, Sohlberg S, Norring C. Negative self-image and outcome in eating disorders: results at 3-year follow-up. Eating Behaviors. August 2007;8(3):398-406. [Medline].

  96. Fosse GK, Holen A. Childhood maltreatment in adult female psychiatric outpatients with eating disorders. Eating Behaviors. November 2006;7(4):404-409. [Medline].

  97. Micali N, Holliday J, Karwautz A, Haidvogl M, Wagner G, Fernandez-Aranda F, et al. Childhood eating and weight in eating disorders: a multi-centre European study of affected women and their unaffected sisters. Psychotherapy and Psychosomatics. 2007;76(4):234-241. [Medline].

  98. Fernández-Aranda F, Krug I, Granero R, Ramón JM, Badia A, Giménez L, et al. Individual and family eating patterns during childhood and early adolescence: an analysis of associated eating disorder factors. Appetite. September 2007;49(2):476-485. [Medline].

  99. Mikami AY, Hinshaw SP, Patterson KA, Lee JC. Eating pathology among adolescent girls with attention-deficit/hyperactivity disorder. Journal of Abnormal Psychology. February 2008;117(1):225-235. [Medline].

  100. Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB. Should bulimia nervosa be subtyped by history of anorexia nervosa? A longitudinal validation. International Journal of Eating Disorders. November 2007;40 Supplement:S67-S71. [Medline]. [Full Text].

  101. Woodside BD, Staab R. Management of psychiatric comorbidity in anorexia nervosa and bulimia nervosa. CNS Drugs. 2006;20(8):655-663. [Medline].

  102. Micali N, Treasure J, Simonoff E. Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity. Journal of Psychosomatic Research. September 2007;63(3):297-303. [Medline].

  103. [Best Evidence] Micali N, Simonoff E, Treasure J. Risk of major adverse perinatal outcomes in women with eating disorders. British Journal of Psychiatry. March 2007;190:255-259. [Medline]. [Full Text].

  104. Chizawsky LL, Newton MS. Eating disorders: identification and treatment in obstetrical patients. Association of Women's Health, Obstetric and Neonatal Nurses. December 2006 - January 2007;10(6):482-488. [Medline]. [Full Text].

  105. Morgan JF, Lacey JH, Chung E. Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study. Psychosomatic Medicine. May/June 2006;68(3):487-492. [Medline].

  106. Marsden P, Karagianni E, Morgan JF. Spirituality and clinical care in eating disorders: a qualitative study. International Journal of Eating Disorders. January 2007;40:7-12. [Medline]. [Full Text].

  107. Richards PS, Berrett ME, Hardman RK, Eggett DL. Comparative efficacy of spirituality, cognitive, and emotional support groups for treating eating disorder inpatients. Eating Disorders. October-December 2006;14:401-415. [Medline].

  108. Graap H, Bleich S, Herbst F, Trostmann Y, Wancata J, de Zwaan M. The needs of carers of patients with anorexia and bulimia nervosa. European Eating Disorders Review. January 2008;16(1):21-29. [Medline]. [Full Text].

  109. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer- term outcomes. Psychopharmacol Bull. 1997;33(3):433-6. [Medline].

  110. American Psychiatric Association. Practice guideline for eating disorders. American Journal of Psychiatry. 1993;150:212-228.

  111. American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry. 2000;157 (supplement):1-39.

  112. Andersen AE. Eating disorders in males. in Brownell KD and Fairburn CG. Eating disorders and Obesity. 1995;177-182.

  113. Arnow BA. Why are empirically supported treatments for bulimia nervosa underutilized and what can we do about it?. J Clin Psychol. Jun 1999;55(6):769-79. [Medline].

  114. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med. Apr 8 1999;340(14):1092-8. [Medline].

  115. Beumont PJV. The clinical presentation of anorexia and bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;151-158.

  116. Beumont PJV, Touyz SW. The clinical presentation of anorexia and bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;306-312.

  117. Braun DL, Sunday SR, Huang A, Halmi KA. More males seek treatment for eating disorders. Int J Eat Disord. May 1999;25(4):415-24. [Medline].

  118. Brownell KD. Eating disorders in athletes. In: Brownell KD, Fairburn CG, eds. Eating disorders and Obesity. 1995;191-198.

  119. Bryant-Waugh R, Lask B. Childhood onset eating disorders. In: Brownell KD, Fairburn CG, eds. Eating disorders and Obesity. 1995;183-187.

  120. Bulik CM, Sullivan PF, Wade TD, Kendler KS. Twin studies of eating disorders: a review. Int J Eat Disord. Jan 2000;27(1):1-20. [Medline].

  121. Carlat DJ, Camargo CA Jr. Review of bulimia nervosa in males. Am J Psychiatry. Jul 1991;148(7):831-43. [Medline].

  122. Carmichael KA, Carmichael DH. Bone metabolism and osteopenia in eating disorders. In: Medicine. Baltimore. 1995;74:254-267.

  123. Caruso D, Klein H. Diagnosis and treatment of bulimia nervosa. Semin Gastrointest Dis. Oct 1998;9(4):176-82. [Medline].

  124. Comerci GD. Medical complications of anorexia nervosa and bulimia nervosa. Med Clin North Am. Sep 1990;74(5):1293-310. [Medline].

  125. Crago M, Shisslak CM, Estes LS. Eating disturbances among American minority groups: a review. Int J Eat Disord. Apr 1996;19(3):239-48. [Medline].

  126. Crow SJ, Mitchell JE. Integrating cognitive therapy and medications in treating bulimia nervosa. Psychiatr Clin North Am. Dec 1996;19(4):755-60. [Medline].

  127. Fairburn CG. Bulimia nervosa. BMJ. Feb 24 1990;300(6723):485-7. [Medline].

  128. Fairburn CG. Short term psychological treatments for bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;344-348.

  129. Fairburn CG, Walsh BT. Atypical eating disorders. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;135-140.

  130. Farrow JA. The adolescent male with an eating disorder. Pediatr Ann. Nov 1992;21(11):769-74. [Medline].

  131. Fisher M, Golden NH, Katzman DK, et al. Eating disorders in adolescents: a background paper. J Adolesc Health. Jun 1995;16(6):420-37. [Medline].

  132. Garfinkel PE. Classification and diagnosis of eating disorders. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;125-134.

  133. Hetherington MM. Eating disorders: diagnosis, etiology, and prevention. Nutrition. Jul-Aug 2000;16(7-8):547-51. [Medline].

  134. Hoek HW. The distribution of eating disorders. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;207-211.

  135. Hofland SL, Dardis PO. Bulimia nervosa. Associated physical problems. J Psychosoc Nurs Ment Health Serv. Feb 1992;30(2):23-7. [Medline].

  136. Holden RJ, Pakula IS. The role of tumor necrosis factor-alpha in the pathogenesis of anorexia and bulimia nervosa, cancer cachexia and obesity. Med Hypotheses. Dec 1996;47(6):423-38. [Medline].

  137. Hsu LK. Epidemiology of the eating disorders. Psychiatr Clin North Am. Dec 1996;19(4):681-700. [Medline].

  138. Hsu LKG. Outcome of bulimia nervosa. In: Brownell KD, Fairburn, CG eds. Eating Disorders and Obesity. 1995;238-246.

  139. Johnson C. Psychodynamic treatment of bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;349-353.

  140. Kaltiala-Heino R, Rissanen A, Rimpelä M, Rantanen P. Bulimia and bulimic behaviour in middle adolescence: more common than thought?. Acta Psychiatr Scand. Jul 1999;100(1):33-9. [Medline].

  141. Katz JL. Eating disorders: a primer for the substance abuse specialist: 1. Clinical features. J Subst Abuse Treat. 1990;7(3):143-9. [Medline].

  142. Kaye W, Strober M, Stein D, Gendall K. New directions in treatment research of anorexia and bulimia nervosa. Biol Psychiatry. May 15 1999;45(10):1285-92. [Medline].

  143. Kaye WH, Klump KL, Frank GK, Strober M. Anorexia and bulimia nervosa. Annu Rev Med. 2000;51:299-313. [Medline].

  144. Kaye WH, Weltzin TE. Neurochemistry of bulimia nervosa. J Clin Psychiatry. Oct 1991;52 Suppl:21-8. [Medline].

  145. Kreipe RE, Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am. Jul 2000;84(4):1027-49, viii-ix. [Medline].

  146. Lacey JH. Inpatient treatment of multi-impulsive bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;361-368.

  147. Laue L, Gold PW, Richmond A, Chrousos GP. The hypothalamic-pituitary-adrenal axis in anorexia nervosa and bulimia nervosa: pathophysiologic implications. Adv Pediatr. 1991;38:287-316. [Medline].

  148. Mcgilley BM, Pryor TL. Assessment and treatment of bulimia nervosa. Am Fam Physician. Jun 1998;57(11):2743-50. [Medline].

  149. Mitchell JE. Medical complications of bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;271-277.

  150. Muscari ME. Thin line: managing care for adolescents with anorexia and bulimia. MCN Am J Matern Child Nurs. May-Jun 1998;23(3):130-40; quiz 141. [Medline].

  151. Parry-Jones B, Parry-Jones WL. History of Bulimia and Bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;145-150.

  152. Patel DR, Phillips EL, Pratt HD. Eating disorders. Indian J Pediatr. Jul-Aug 1998;65(4):487-94. [Medline].

  153. Pirke KM. Physiology of bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;261-265.

  154. Robinson PH. Review article: recognition and treatment of eating disorders in primary and secondary care. Aliment Pharmacol Ther. Apr 2000;14(4):367-77. [Medline].

  155. Sokol MS, Steinberg D, Zerbe KJ. Childhood eating disorders. Curr Opin Pediatr. Aug 1998;10(4):369-77. [Medline].

  156. Strober M. Family-genetic perspectives on anorexia nervosa and bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;212-218.

  157. Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord. Dec 1997;22(4):339-60. [Medline].

  158. Stunkard A. Eating disorders: the last 25 years. Appetite. Oct 1997;29(2):181-90. [Medline].

  159. Thomas MA, Rebar RW. The endocrinology of anorexia nervosa and bulimia nervosa. Curr Opin Obstet Gynecol. Dec 1990;2(6):831-6. [Medline].

  160. Tuschen B, Bents H. Intensive brief inpatient treatment of bulimia nervosa. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;354-360.

  161. Vaz FJ. Outcome of bulimia nervosa: prognostic indicators. J Psychosom Res. Nov 1998;45(5):391-400. [Medline].

  162. Walsh BT. Pharmacotherapy of eating disorders. In: Brownell KD, Fairburn CG, eds. Eating Disorders and Obesity. 1995;313-317.

  163. Walsh BT, Devlin MJ. Eating disorders: progress and problems. Science. May 29 1998;280(5368):1387-90. [Medline].

  164. Wilson GT. Treatment of bulimia nervosa: when CBT fails. Behav Res Ther. Mar 1996;34(3):197-212. [Medline].

  165. Wilson GT, Vitousek KM, Loeb KL. Stepped care treatment for eating disorders. J Consult Clin Psychol. Aug 2000;68(4):564-72. [Medline].

  166. Yanovski SZ. Biological correlates of binge eating. Addict Behav. Nov-Dec 1995;20(6):705-12. [Medline].

  167. Yanovski SZ. Obesity and eating disorders. In: Bray GA, Bouchard C, James WPT, eds. Handbook of Obesity. 1997:115-128.

  168. Ziolko HU. Bulimia: a historical outline. Int J Eat Disord. Dec 1996;20(4):345-58. [Medline].

[ CLOSE WINDOW ]

Keywords

bulimia nervosa, BN, binge-eating/purging eating disorder, binge-eating disorder, BED, binging and purging, pathological voracity, cynorexia, kynorexia, morbid hunger, eating disorder, ED, excessive exercise, fasting, dieting, self-induced vomiting, diuretic abuse, laxative abuse, use of appetite suppressants, thyroid hormone, subjective bulimic episode

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Raj K Kalapatapu, MD, Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons
Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kelda Harris Walsh, MD, Assistant Professor of Clinical Psychiatry, Section of Child and Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Chief, Obsessive-Compulsive/Tourette/Anxiety Disorders Clinic, Riley Hospital for Children
Kelda Harris Walsh, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, MedStar Research Institute and Washington Hospital Center
Gabriel I Uwaifo, MBBS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Society of Hypertension, and Endocrine Society
Disclosure: Nothing to disclose.

Robert C Daly, MB, ChB, MPH, BCh, Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University 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.

CME Editor

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 Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.