Bulimia Nervosa Follow-up

Updated: Feb 28, 2020
  • Author: Donald M Hilty, MD, MBA; Chief Editor: David Bienenfeld, MD  more...
  • Print

Further Outpatient Care

Most authorities agree that patients with bulimia nervosa (BN) who have benefited from CBT are likely to benefit from a program of relapse prevention as well, lasting usually 1–2 years. Since simply telling patients with bulimia nervosa who have achieved abstinence following a course of CBT to return for additional sessions if they fear relapse has been ineffective for preventing relapse, planned visits or regularly scheduled phone calls might be used. [106]



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. [107]



Psychiatric complications

Studies suggest that patients with bulimia nervosa (BN) have increased rates of major depressive disorder, 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. Patients with BN who are depressed and who have concurrent alcohol dependence are at exceptionally high risk of suicide, particularly those who overexercise. Studies have shows that in people with eating disorders, excessive exercise appears to be linked to an increased prevalence of acquired capability for suicide (ACS) and suicide attempts. [108, 109]

Medical complications

The all-cause mortality rate for BN per se is slightly lower than for anorexia nervosa (AN) (3.9% vs 4.0%, respectively). [53] Medical complications do arise and should be assessed carefully.

While the results of formal gastric emptying studies in patients with BN 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 BN.

Xerosis (dry skin) is a common finding in bulimia nervosa, which appears to be related to the chronic dehydration to which persons with BN 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.



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. [110] 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. [111]

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. [112]

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. [113] 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. [10] 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. [114]

Consistent predictors of outcome have not yet been identified. However, the severity of the purging sequelae, negative self-image, [115] childhood maltreatment, [116] childhood obesity/overeating, [117] individual/family eating patterns during childhood/early adolescence, [118] and ADHD [119] 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. [120]


Patient Education

Cognitive behavioral therapy remains the therapeutic method of choice for bulimia nervosa, and various modifications of this technique are actively under investigation. Most of these interventions include the premise that education about bulimia nervosa in a nonthreatening environment has a therapeutic effect. These types of therapy are conducted in either individual or group settings. Educational components of treatment address the following issues:

  • The multifactorial etiology of eating disorders with biologic, genetic, psychological, familial, and sociocultural factors

  • Medical complications related to vomiting, laxative, and diuretic abuse

  • The set-point theory of weight regulation and the potential consequences of weight cycling and cyclic dieting

  • Basic nutritional information

  • Sociocultural and body image issues

  • Cognitive and behavioral strategies

  • Relapse prevention and management of occasional binge eating "slips"

More than 70% of published management studies of bulimia nervosa involve some form of psychoeducational program. Although no “unbundling” studies have been conducted that exclude psychoeducation to assess the relative contribution of this specific strategy to overall treatment outcomes, anecdotal reports and the personal experiences of many practitioners suggest that for at least some patients the educational information helps significantly.

Family members can provide perspectives on factors contributing to the onset of the disorder and issues that may help or hamper recovery efforts, and their involvement is often critical to sustained recovery. In addition to empathically listening to family members, clinicians should educate and advise them on the nature of the disorder and their interactions with the patient. When indicated, and with the patient’s consent, families should be involved in treatment. Such involvement may contribute to the likelihood of better outcomes. [8]

For excellent patient education resources, visit eMedicineHealth's Women's Health Center. Also, see eMedicineHealth's patient education article Bulimia.

For further information, see the following Web sites:

Below is a list of workbooks and books for bulimia nervosa:

  • Sandoz E, Wilson K, Dufrene T: The Mindfulness and Acceptance Workbook for Bulimia: A Guide to Breaking Free from Bulimia using Acceptance and Commitment Therapy. Oakland, CA, New Harbinger Publications, Inc, 2011

  • Astrachan-Fletcher E, Maslar M: The Dialectical Behavior Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. Oakland, CA, New Harbinger Publications, Inc, 2009

  • Miller C: My Name Is Caroline, second edition. New York, Cogent Publishing, 2014

  • Miller C: Positively Caroline. New York, Cogent Publishing, 2013

  • Feigenbaum N: Maintaining Recovery From Eating Disorders: Avoiding Relapse and Recovering Life. London, UK, Jessica Kingsley Publishers, 2012

  • DeSole L: Eating Disorders and Mindfulness: Exploring Alternative Approaches to Treatment. New York, Routledge, 2014

  • Fairburn C: Overcoming Binge Eating, second edition. New York, Guilford, 2013

  • Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): second edition, A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 2015

Other books reported to be helpful by patients/families include the following:         

  • Bulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005

  • Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005

  • Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005