eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder: Bulimia: Follow-up

Author: Megan A Moreno, MD, MSEd, Department of Pediatrics, Adolescent Medicine and STD/HIV Fellow, Children's Hospital and Regional Medical Center
Coauthor(s): Robert Judd, MD, Associate Professor, Department of Pediatrics, Division of Pediatric Gastroenterology, University of Wisconsin at Madison
Contributor Information and Disclosures

Updated: Feb 25, 2008

Follow-up

Further Inpatient Care

• Inpatient care is warranted if patient is suicidal, has abnormal ECG findings or electrolyte levels, is dehydrated, or has had no response to outpatient therapy.
• Inpatient care should include the following:
  • Supervised meals
  • Supervised bathroom privileges
  • No access to bathroom for 2 hours after eating
  • Monitoring of weight and physical activity
  • Assessment of nutritional state
  • Identifications of precipitants to binge and purge
  • Frequent assessment of electrolytes
  • Individual psychotherapy
  • Frequent doctor visits

Further Outpatient Care

• The 2 standard approaches to outpatient care are counseling and medication; these are not mutually exclusive. A combination of these methods has been found to be most effective in patients with bulimia nervosa (BN)
• The most studied form of outpatient care for patients with bulimia is CBT. A specific form of CBT has been created for patients with bulimia and is termed CBT-BN. CBT has been shown to have significantly better results in patients with BN than other forms of psychotherapy.
  • This form of therapy is usually short-term (4-6 mo).
  • CBT focuses on patients' preoccupation with body shape and weight, persistent dieting, and binge eating and purging.
  • Patients are asked to monitor thoughts, feelings, and circumstances surrounding binge-purge episodes. Patients may be asked to keep a food diary and record feelings and urges to binge or purge along with foods the patient consumed during the day. By examining the cues that lead patients to binge, patients can learn to avoid these cues or to redirect their feelings when the cues emerge. These strategies can also help patients challenge their fears of loss of control.
  • Patients are also instructed to cease dieting and begin regular eating. By quitting dieting and removing the feeling of being restricted in what one can eat, patients are less likely to binge on "forbidden foods."
  • Patients are also asked to systematically challenge their assumptions linking weight to self-esteem.
  • Therapy is focused on building trust and developing a treatment alliance.
  • Patients are involved in setting the treatment goals.
  • Some patients benefit from self-help groups. Family involvement in treatment is welcomed and encouraged.
  • The goal of care is to focus on the overall well being of the patient.
• The second approach to treatment is the use of medications.
  • The use of antidepressant medications, such as fluoxetine or a TCA, was initially based on an association between BN and mood disturbance.
  • More than 12 double-blind placebo-controlled trials have shown that antidepressants help patients reduce binge frequency.
• Other staples of outpatient care include nutritional counseling and meal planning.
• Relaxation strategies are helpful for some patients.
• Other forms of therapy with unclear benefit include interpersonal psychotherapy, hypnobehavioral therapy, dialectical behavior therapy, and motivational enhancement therapy. These therapies have not been adequately studied in patients with BN.

Inpatient & Outpatient Medications

See Medication.

Deterrence/Prevention

• Prevention efforts have centered on counseling to encourage rational attitudes about weight, moderation of overly high self-expectations, enhancement of self-esteem, and alleviation of stress and stimulating a healthy body image.
• Prevention efforts can be pursued in primary care physicians' offices during health supervision visits.

Complications

• Many complications to bulimia are possible, including the following:
  • CNS - Seizures
  • Cardiac - Cardiac arrhythmias secondary to hypokalemia; can lead to cardiac arrest, cardiac rupture, and cardiomyopathy secondary to ipecac abuse
  • Pulmonary - Pulmonary aspiration of gastric contents, pneumomediastinum
  • GI - Esophageal rupture, esophagitis, delayed gastric emptying, pancreatitis
  • Musculoskeletal - Muscle weakness secondary to ipecac abuse and potassium irregularities, tetany
  • Renal - Impaired renal function
  • Psychiatric - Depression, suicide attempts, substance abuse

Prognosis

• CBT has been shown to benefit patients. Evidence suggests persistent benefit 4 years after treatment; however, treatment benefit greatly depends on accessibility to CBT-trained therapists. Therapists with expertise in CBT may be difficult to find outside of established centers.
• Medication therapy has also been shown to benefit patients; however, only a minority of patients achieve full remission on medication alone. Limited data suggest that a considerable rate of relapse is observed once medications are discontinued.
• Studies have shown that patients who receive treatment (CBT or medication) demonstrate benefit. One study compared treated versus nontreated patients 6 months after initial presentation.⁴ Follow-up studies reported that 28-33% women without treatment were in remission, and follow-up studies of treated women reported 21-75% successful remissions.
  • After one year, follow-up studies reported 28-33% of patients without treatment were in remission, and 5-83% of women in treatment were in remission.
  • Follow-up studies reported a range of 13-69% of patients still in remission without ongoing treatment 2-4 years after initial remission. These data were compared to data pertaining to women who were still in treatment; these women had remission ranges of 46-50%. Over 5 years of follow-up, untreated women had maintained remission rates around 31-60%. This was compared to women who were still in treatment, who had an average remission rate of 54%. Women in treatment outcome studies had higher rates of remission than women in studies who did not receive treatment.
  • Overall, 5-10 years following presentation, approximately 50% of all women with BN fully recover, and 20% still have full BN.
• Given that eating disorders only have been defined and studied as diseases for 20 years, limited long-term data on prognosis exist. The imprecise, inconsistent, and often confusing data on remission rates and percentages available for patient follow-up are evidence that more research and follow-up are needed.
• Overall, despite advances in medical care and therapy, the prognosis for patients with bulimia remains guarded. Even in the best of hands, both medications and therapy fail in 33-50% of patients. The relapse rate remains around 30%, and patient crossover to AN from BN ranges from 0-7%.
• Studies have shown that patients with bulimia who have a previous diagnosis of AN are more likely to have a protracted illness or relapse into AN during follow up compared with patients with bulimia with no history of AN.⁵

Patient Education

• Education of patients and families involves teaching the seriousness and consequences of bulimic behavior.
• Information about complications and physiologic changes that can occur as a result of bulimia is important to convey to patients and families.
• Information on proper nutrition and metabolic balance is also helpful.
• For excellent patient education resources, visit eMedicine's Eating Disorders Center. Also, see eMedicine's patient education article Bulimia.

Miscellaneous

Medicolegal Pitfalls

• Because many patients with bulimia nervosa (BN) have concomitant psychiatric disorders, screening patients for suicidal intentions is worthwhile.

Special Concerns

• One research group in the United Kingdom has designed a screening tool to be used for patients in whom bulimia is suspected.⁶ This questionnaire, called the SCOFF (sick, control, one, fat, food) questionnaire, is designed to be similar to the CAGE ([need to] cut down [on drinking], annoyance, guilt [about drinking], [need for] eye-opener) questionnaire used in alcoholism screening. These 5 questions are designed to address core features of AN and BN. The false-positive result rate is approximately 12.5%. The test has very high sensitivity. One point per yes answer is added, and a score greater than 2 indicates a likely case of AN or BN. The questions are as follows:
• Do you make yourself sick because you feel uncomfortably full? 
• Do you worry you have lost control over how much you eat?
• Have you recently lost more than one stone in a 3-month period? (A stone is a United Kingdom measurement of weight and equals approximately 14 lb.)
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

• Search for CME/CE on This Topic »

• Eating Disorders Center
• Bulimia Overview
• Bulimia Causes
• Bulimia Treatment
• Bulimia Symptoms

• Eating Disorders Resource Center