Medical Care

Inpatient care is warranted if the patient is suicidal, has abnormal ECG findings or electrolyte levels, is dehydrated, or has had no response to outpatient therapy. Intensive outpatient treatment is currently being evaluated as an alternative to inpatient care.^{[23, 24, 25]}

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. If underweight, patients will often attempt to artificially increase their weight by drinking water, not emptying their bladder or hiding weighted objects in their clothing prior to known weighing periods.
Assessment of nutritional state
Identifications of precipitants to binge and purge
Frequent assessment of electrolytes
Individual psychotherapy^[26]
Frequent doctor visits

See Further Outpatient Care for outpatient management.^{[4, 5, 6, 7, 9]}

Future directions

In addition to medications and therapy, there has been some preliminary work investigating effects of brain stimulation and neuromodulation in adults with bulimia. Further research is needed to see if transcranial magnetic stimulation will become an effective modality in treating bulimia and other eating disorders.^{[27, 28]}

Surgical Care

Surgical care is indicated only in cases in which gastric or esophageal ruptures are suspected.^{[4, 5, 7, 8]}

Consultations

Cognitive behavior therapy (CBT) has been shown to improve outcomes in patients with bulimia. Referral to a mental health provider with experience in CBT is recommended.

Dental consultation is appropriate to help avoid progression of enamel erosion due to frequent vomiting.

Nutrition consultation can be very helpful in guiding patients toward normal eating patterns and healthy food choices.

Diet

Emphasis in diet instruction is on eating balanced meals, achieving a normal eating pattern, and consuming adequate calories.

Another goal is to reintroduce feared foods that patients previously binged on in small amounts, allowing patients to enjoy these foods without overeating.

Activity

Patient and family should be counseled to monitor excess activity. Practitioners should stress the importance of playful, pleasurable activities to reduce stress.

Guidelines

Douglas D. Leptin Levels Tied to Binge Eating in Children. Available at http://www.medscape.com/viewarticle/809678. Accessed: August 29, 2013.
Valenzuela F, Lock J, Le Grange D, Bohon C. Comorbid depressive symptoms and self-esteem improve after either cognitive-behavioural therapy or family-based treatment for adolescent bulimia nervosa. Eur Eat Disord Rev. 2018 Feb 15. [QxMD MEDLINE Link].
Behrman RE, Kliegman R, Jenson HB. Nelson's Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders and Co; 2000.
Neinstein LS, Gordon CM, Katzman DK, Rosen DS, Woods ER. Adolescent Health Care, A Practical Guide. 5th ed. Philadelphia, PA: Wolters Kuwer and Lippincott Williams & Wilkins; 2008.
Haly PJ, Bacaltchuk J. Bulimia Nervosa. American Family Physician. June 2007. 75:1699-702.
Walsh BT, Devlin MJ. Eating disorders: progress and problems. Science. 1998 May 29. 280(5368):1387-90. [QxMD MEDLINE Link].
Strasburger VC, Brown RT, Braverman PK, Rogers PD, Holland-Hall C, Coupey SM. Adolescent Medicine, A Handbook for Primary Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
Herpertz-Dahlmann B. Adolescent eating disorders: definitions, symptomatology, epidemiology and comorbidity. Child Adolesc Psychiatr Clin N Am. 2009 Jan. 18(1):31-47. [QxMD MEDLINE Link].
Sigel E. Eating disorders. Adolesc Med State Art Rev. 2008 Dec. 19(3):547-72, xi. [QxMD MEDLINE Link].
Carney CP, Andersen AE. Eating disorders. Guide to medical evaluation and complications. Psychiatr Clin North Am. 1996 Dec. 19(4):657-79. [QxMD MEDLINE Link].
Halmi KA. Models to conceptualize risk factors for bulimia nervosa. Arch Gen Psychiatry. 1997 Jun. 54(6):507-8. [QxMD MEDLINE Link].
Cotran RS, Kumar V, Collins T. Robbins Pathologic Basis of Disease. 6th ed. Philadelphia, Pa: WB Saunders and Co; 1999.
Capasso A, Putrella C, Milano W. Recent clinical aspects of eating disorders. Rev Recent Clin Trials. 2009 Jan. 4(1):63-9. [QxMD MEDLINE Link].
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. Int J Eat Disord. 2007 Nov. 40(7):589-95. [QxMD MEDLINE Link]. [Full Text].
Muise AM, Stein DG, Arbess G. Eating disorders in adolescent boys: a review of the adolescent and young adult literature. J Adolesc Health. 2003 Dec. 33(6):427-35. [QxMD MEDLINE Link].
Lilly RZ. Bulimia nervosa. BMJ. 2003 Aug 16. 327(7411):380-1. [QxMD MEDLINE Link]. [Full Text].
Heaner MK, Walsh BT. A history of the identification of the characteristic eating disturbances of Bulimia Nervosa, Binge Eating Disorder and Anorexia Nervosa. Appetite. 2013 Jun 7. [QxMD MEDLINE Link].
Nicholls D, Viner R. Eating disorders and weight problems. BMJ. 2005 Apr 23. 330(7497):950-3. [QxMD MEDLINE Link]. [Full Text].
Spindler A, Milos G. Links between eating disorder symptom severity and psychiatric comorbidity. Eat Behav. 2007 Aug. 8(3):364-73. [QxMD MEDLINE Link].
Mitchell JE. The Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians, and Physicians. University of Minnesota Press; 2001. 32.
Le Grange D, Lock J. Treating Bulimia in Adolescents- A Family Based Approach. New York, NY: The Guilford Press; 2007.
Weddle M, Kokotailo P. Adolescent substance abuse. Confidentiality and consent. Pediatr Clin North Am. April 2002. 49:301-15. [QxMD MEDLINE Link].
Berkman ND, Bulik CM, Brownley KA, Lohr KN, Sedway JA, Rooks A, et al. Management of eating disorders. Evid Rep Technol Assess (Full Rep). 2006 Apr. 1-166. [QxMD MEDLINE Link]. [Full Text].
Ornstein RM, Lane-Loney SE, Hollenbeak CS. Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders. Eat Weight Disord. 2012 Sep. 17(3):e170-7. [QxMD MEDLINE Link].
Lock J. Treatment of Adolescent Eating Disorders: Progress and Challenges. Minerva Psichiatr. 2010 Sep. 51(3):207-216. [QxMD MEDLINE Link]. [Full Text].
Linardon J, Wade T, de la Piedad Garcia X, Brennan L. Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials. Int J Eat Disord. 2017 Oct. 50 (10):1124-1136. [QxMD MEDLINE Link].
Claudino AM, Van den Eynde F, Stahl D, Dew T, Andiappan M, Kalthoff J. Repetitive transcranial magnetic stimulation reduces cortisol concentrations in bulimic disorders. Psychol Med. 2011 Jun. 41(6):1329-36. [QxMD MEDLINE Link].
Van den Eynde F, Claudino AM, Mogg A, Horrell L, Stahl D, Ribeiro W. Repetitive transcranial magnetic stimulation reduces cue-induced food craving in bulimic disorders. Biol Psychiatry. 2010 Apr 15. 67(8):793-5. [QxMD MEDLINE Link].
Couturier J, Isserlin L, Norris M, et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord. 2020. 8:4. [QxMD MEDLINE Link].
Bacaltchuk J, Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev. 2003. CD003391. [QxMD MEDLINE Link]. [Full Text].
Hay PJ, Bacaltchuk J, Stefano S. Psychotherapy for bulimia nervosa and binging. Cochrane Database Syst Rev. 2004. (3):CD000562. [QxMD MEDLINE Link]. [Full Text].
Milano W, Siano C, Putrella C, Capasso A. Treatment of bulimia nervosa with fluvoxamine: a randomized controlled trial. Adv Ther. 2005 May-Jun. 22(3):278-83. [QxMD MEDLINE Link].
Milano W, Petrella C, Sabatino C, Capasso A. Treatment of bulimia nervosa with sertraline: a randomized controlled trial. Adv Ther. 2004 Jul-Aug. 21(4):232-7. [QxMD MEDLINE Link].
Aigner M, Treasure J, Kaye W, Kasper S,. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry. 2011 Sep. 12(6):400-43. [QxMD MEDLINE Link].
March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004 Aug 18. 292(7):807-20. [QxMD MEDLINE Link].
Hartman BK, Faris PL, Kim SW, Raymond NC, Goodale RL, Meller WH, et al. Treatment of bulimia nervosa with ondansetron. Arch Gen Psychiatry. 1997 Oct. 54(10):969-70. [QxMD MEDLINE Link].
Waller G, Gray E, Hinrichsen H, Mountford V, Lawson R, Patient E. Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: effectiveness in clinical settings. Int J Eat Disord. 2014 Jan. 47(1):13-7. [QxMD MEDLINE Link].
Agüera Z, Riesco N, Jiménez-Murcia S, Islam MA, Granero R, Vicente E. Cognitive behaviour therapy response and dropout rate across purging and nonpurging bulimia nervosa and binge eating disorder: DSM-5 implications. BMC Psychiatry. 2013. 13:285. [QxMD MEDLINE Link].
Zeeck A, Weber S, Sandholz A, Wetzler-Burmeister E, Wirsching M, Hartmann A. Inpatient versus day clinic treatment for bulimia nervosa: a randomized trial. Psychother Psychosom. 2009. 78(3):152-60. [QxMD MEDLINE Link].
Fairburn CG, Cooper Z, Doll HA, O'Connor ME, Bohn K, Hawker DM, et al. Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry. 2009 Mar. 166(3):311-9. [QxMD MEDLINE Link].
Vaz AR, Conceição E, Machado PP. Early response as a predictor of success in guided self-help treatment for bulimic disorders. Eur Eat Disord Rev. 2014 Jan. 22(1):59-65. [QxMD MEDLINE Link].
Linna MS, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Reproductive health outcomes in eating disorders. Int J Eat Disord. 2013 Dec. 46(8):826-33. [QxMD MEDLINE Link].
Forman SF, Grodin LF, Graham DA, Sylvester CJ, Rosen DS, Kapphahn CJ, et al. An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses. J Adolesc Health. 2011 Dec. 49(6):594-600. [QxMD MEDLINE Link].
Hagan KE, Clark KE, Forbush KT. Incremental validity of weight suppression in predicting clinical impairment in bulimic syndromes. Int J Eat Disord. 2017 Jun. 50 (6):672-678. [QxMD MEDLINE Link].
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. Int J Eat Disord. 2007 Nov. 40 Suppl:S67-71. [QxMD MEDLINE Link]. [Full Text].
National Eating Disorders Association. National Eating Disorders Association. Available at http://www.nationaleatingdisorders.org/. Accessed: April 2009.
Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999 Dec 4. 319(7223):1467-8. [QxMD MEDLINE Link]. [Full Text].
Miller R, Tanofsky-Kraff M, Shomaker LB, Field SE, Hannallah L, Reina SA, et al. Serum leptin and loss of control eating in children and adolescents. Int J Obes (Lond). 2013 Jul 9. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Maggie A Wilkes, MD Resident Physician, Department of Psychiatry, Medical University of South Carolina College of Medicine

Maggie A Wilkes, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Eve G Spratt, MD, MSc Professor of Pediatrics and Psychiatry, Division of Developmental Pediatrics, Medical University of South Carolina; Director, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina Children's Hospital at Charleston

Eve G Spratt, MD, MSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Angelo P Giardino, MD, PhD, MPH, FAAP Wilma T Gibson Presidential Professor and Chair, Department of Pediatrics, University of Utah School of Medicine; Chief Medical Officer, Intermountain Primary Children's Hospital

Angelo P Giardino, MD, PhD, MPH, FAAP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Nothing to disclose.

Acknowledgements

Libby N Brockman Clinical Research Assistant, Center for Clinical and Translational Research, Seattle Children's Hospital; Research Assistant, Department of Pediatrics, University of Washington, Seattle

Disclosure: Nothing to disclose.

Robert Judd, MD Associate Professor, Department of Pediatrics, Division of Pediatric Gastroenterology, University of Wisconsin at Madison

Robert Judd, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Megan A Moreno, MD, MEd, MPH Assistant Professor, Department of Pediatrics, Section of Adolescent Medicine, University of Wisconsin-Madison School of Medicine and Public Health

Megan A Moreno, MD, MEd, MPH is a member of the following medical societies: Society for Adolescent Medicine

Disclosure: Nothing to disclose.

Patricia Quigley, MD Resident Physician, Department of Pediatrics, University of Wisconsin Hospital and Clinics

Patricia Quigley, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.