Guidelines Summary

American Psychiatric Association

The American Psychiatric Association (APA) published guidelines for the treatment of eating disorders in February 2023.^{[120, 121]}The guidelines recommend that screening for the presence of an eating disorder should be part of an initial psychiatric evaluation. The initial evaluation of a patient with a possible eating disorder should include assessment of multiple factors, including but not limited to, patient’s history of height and weight, eating-related behaviors, food repertoire, weight control behaviors, and family history. The evaluation should also identify co-occurring health conditions and psychiatric disorders.

Adults with bulimia nervosa (BN) should be treated with eating disorder–focused cognitive-behavioral therapy and prescribed a serotonin reuptake inhibitor.

Canadian practice guidelines

Canadian practice guidelines for treating children and adolescents with eating disorders were published in 2020.^[122]Recommendations include the following:

Family-based treatment (FBT) is strongly recommended for children and adolescents with anorexia nervosa or bulimia nervosa.
Multi-family therapy (MFT) is a reasonable treatment option for children and adolescents with anorexia nervosa.
Cognitive-behavioral therapy (CBT) is a reasonable treatment option for children and adolescents with anorexia nervosa or bulimia nervosa.
Adolescent-focused therapy (AFP) is a reasonable treatment option for children and adolescents with anorexia nervosa.
Yoga, in addition to standard treatments, is a reasonable treatment option for medically stable children and adolescents with anorexia nervosa, bulimia nervosa, and other specified feeding and eating disorders.
Olanzapine or aripiprazole may be reasonable treatment options for certain populations of children and adolescents with anorexia nervosa if monitored carefully.
It is strongly recommended that the least intensive treatment environment be provided, especially for those children and adolescents with anorexia nervosa requiring a first admission to hospital and/or with a duration of illness less than 3 years.

Follow-up

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Media Gallery

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.

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Differential Diagnosis of Bulimia Nervosa^[1]

Differential Diagnosis of Bulimia Nervosa ^[1]

Anorexia Nervosa	AN and BN	Bulimia Nervosa
Restriction of energy intake relative to requirement, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health		Recurrent episodes of binge eating: a) eating in a discrete period of time, within a 2-hour period, an amount that is definitely larger than what most would eat in that time period; b) a sense of lack of control over eating
Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight		Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
	Disturbance in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight	The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months
Two types: Restrictive and Purge/Bing-Eating type		The disturbance does not occur exclusively during episodes of AN
Body Dysmorphic Disorder	BDD and BN	BN
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others	Disturbance in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation	Recurrent episodes of binge eating: a) eating in a discrete period of time, within a 2-hour period, an amount that is definitely larger than what most would eat in that time period; b) a sense of lack of control over eating
At some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns	The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning	Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder		The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

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Author

Donald M Hilty, MD, MBA Associate Chief of Staff, Mental Health, Northern California VA Healthcare System; Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine

Donald M Hilty, MD, MBA is a member of the following medical societies: American Association for Technology in Psychiatry, American Psychiatric Association, American Telemedicine Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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, American Psychiatric Association

Disclosure: Nothing to disclose.

Lorin M Scher, MD, FACLP Clinical Professor of Psychiatry and Behavioral Sciences, Vice-Chair for Education, Roy T Brophy Endowed Chair, Director, Integrated Behavioral Health Services, Medical Director, Government and Community Relations, UC Davis Health

Lorin M Scher, MD, FACLP is a member of the following medical societies: Academy of Consultation-Liaison Psychiatry, Alpha Omega Alpha, American Medical Association, American Psychiatric Association, Association of Directors of Medical Student Education in Psychiatry, California Medical Association, Central California Psychiatric Society, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Gagandeep Randhawa, MBBS Resident Physician, Department of Psychiatry, Kaweah Delta Medical Center, University of California, Irvine, School of Medicine

Gagandeep Randhawa, MBBS is a member of the following medical societies: American Psychiatric Association, Indian Doctors for Peace and Development

Disclosure: Nothing to disclose.

Acknowledgements

Robert C Daly, MB, ChB, MPH Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health

Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association.

Disclosure: Nothing to disclose.

Gabriel I Uwaifo, MD Associate Professor, Section of Endocrinology, Diabetes and Metabolism, Louisiana State University School of Medicine in New Orleans; Adjunct Professor, Joint Program on Diabetes, Endocrinology and Metabolism, Pennington Biomedical Research Center in Baton Rouge

Gabriel I Uwaifo, MD 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 The Endocrine Society

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

Acknowledgments

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.