Bulimia nervosa diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2] Joseph Nasr, M.D.[3]

Diagnostic Criteria

DSM-V Diagnostic Criteria for Bulimia Nervosa

“

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). AND B. 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. AND C. The binge eating and inappropriate compensatory behaviors both occur, on average,at least once a week for 3 months. AND D. Self-evaluation is unduly influenced by body shape and weight. AND E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some,but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

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BULIMIA NERVOSA

Step 1. Confirm binge eating and loss of control Ask with concrete anchors: 1.Do you have episodes where you eat an unusually large amount of food in a short time? 2.During those episodes, do you feel out of control or unable to stop? 3.How often do these episodes happen per week and for how many months?

Step 2. Identify compensatory behaviors Clarify all methods, not just vomiting: 1.Self induced vomiting 2.Laxatives or diuretics or other medications 3.Fasting or severe restriction after binges 4.Excessive exercise used to compensate 5.Insulin restriction if diabetes is present

Step 3. Apply DSM pattern and exclusions Checklist to document criteria: 1.Binge eating plus compensatory behaviors 2.Frequency at least once weekly for three months 3.Self evaluation unduly influenced by body shape and weight 4.Not occurring exclusively during anorexia nervosa

Step 4. Screen for urgent complications first 1.Syncope, palpitations, chest pain, severe weakness 2.Hematemeis or severe abdominal pain after vomiting 3.Severe dehydration or inability to keep fluids down 4.Suicidality If present, treat as urgent and escalate care

Step 5. Focused symptom review that predicts complications 1.Sore throat, hoarseness, reflux symptoms 2.Dental sensitivity or tooth damage 3.Muscle cramps or weakness suggesting electrolyte disturbance 4.Swelling of cheeks or jaw suggesting salivary gland enlargement

Step 6. Physical examination aimed at purging signs 1.Vitals including orthostatic measurements 2.Oral exam for dental enamel erosion 3.Parotid or salivary gland enlargement 4.Russell sign on knuckles if vomiting is induced 5.Cardiac exam for arrhythmia signs

Step 7. Core investigations 1.Serum electrolytes including sodium, potassium, chloride, bicarbonate 2.Urea and creatinine 3.Magnesium and phosphate if purging is frequent or severe 4.Electrocardiogram for QTc and rhythm abnormalities

Step 8. Differential and overlap 1.If significantly low body weight, consider anorexia nervosa binge eating purging type 2.If no compensatory behaviors, consider binge eating disorder 3.Assess comorbid depression, anxiety, substance use, and self harm risk