Bulimia Diagnostic Criteria

According to the DSM-5, the following are criteria to have a diagnosis of bulimia nervosa (BN) (1,2,3):

• Eating a large amount of food in a small amount of time (less than two hours)—much more than what someone would eat under similar circumstances. This is called a binge eating episode. 
• When binging, the person will report that they have no control over what and how much they eat. 
• Practice recurrent, inappropriate, compensatory behaviors to prevent gaining weight, with examples including:
  • Self-induced vomiting.
  • Misuse of medications with the goal of compensating for food consumed. 
  • Excessive exercise. 
  • Fasting.
• The binge eating and compensatory behaviors both occur, on average, at least once a week for three months.
• Excessive concern about body weight and shape.
• These behaviors do not occur exclusively during episodes of anorexia nervosa (AN).
• The sequence of behavior consists of calorie restriction, binge eating, and self-induced vomiting (or a type of purging behavior). This behavioral pattern is called the restriction model.
• Binge eating is not otherwise better explained by another medical disorder, for example an esophageal or digestive pathology.

Accompanied with these symptoms are feelings of distress, remorse, and self-loathing. The behaviors must cause considerable personal and interpersonal stress. The DSM-5 can further classify patients as being in partial or full remission, depending on the frequency of binge eating episodes and the natural waxing and waning pattern of the illness.

Who Can Diagnose Bulimia Nervosa?

Only licensed health care professionals can formally diagnose someone with any psychiatric disorder. Giving someone this diagnosis will usually require several appointments to gain a full understanding of their history, symptoms, and behaviors. Some providers may also contact family members to gain another view point and more accurate history, as some patients tend to downplay their symptoms. 

Unfortunately, because of embarrassment or denial, some individuals may not readily disclose all of their symptoms to their provider, delaying a necessary diagnosis. When a person first seeks care, it can be very difficult to come to terms with the reality of their illness. Others may feel that they do not want to be a bother and burden their health care provider. It is important to be open, honest, and forthcoming with all symptoms, relapses, triggers, and emotions. Patients may be encouraged to keep a diary of symptoms to better assist their provider.

Qualified diagnostic providers include:

What Are Common Lab Tests to Evaluate for BN?

In addition to a full history and mental status exam, several labs and tests are ordered to fully assess the health of the individual. These include (1,3,5):

What Is the Role of a Self-Assessment?

Some of the core treatment methods for treating BN include (1,3,5):

• Cognitive behavioral therapy (CBT)
• Interpersonal psychotherapy (IPT)
• If there are other underlying psychiatric disorders, dialectical behavioral therapy (DBT) can also be of use.
• Nutritional rehabilitation counseling.
• Family therapy.

While undergoing these types of therapy, performing frequent self-evaluations is critical to recovery. This allows an individual to measure their recovery, while quantitatively placing a number on their progress. The best self-assessment methods include the PHQ-ED, SCOFF, EAT, and ESP surveys.

The Patient Health Questionnaire (PHQ) contains a long list of specific symptoms that someone can experience with BN. Over time, this is an excellent way to determine which symptoms are resolving and which still cause considerable stress (1,3,6).

The SCOFF questionnaire is recommended by the USPSTF and is an acronym to assess feelings around control, food, and body image (3)

The Eating Disorder Screen for Primary Care (ESP) can be a valuable screening tool. The Eating Attitudes Test (EAT) is the most commonly used self-reporting instrument that allows an individual to track if symptoms bother them always, usually, often, something, rarely, or never. This generates a score that is highly informative to both the patient and provider (1).

Is It Difficult to Overcome Bulimia Nervosa Without Additional Support?

As with any illness, addiction, or in times of grief, relying on a stable, loving community is invaluable to recovery. Times of increased distress are expected, which is when friends and family can step in to be accountability partners. Great caution should be taken, however, when choosing a community. In the world of eating disorders, there exist two types of communities (7,8):

1. Those who will help you recover from bulimia nervosa.
2. Those who reinforce disordered eating, especially on the internet.

It may feel wonderful initially to meet other people who struggle with BN and share stories, but often, people can fall into the trap where disordered eating is enabled, encouraged, and excused. 

Finding a firm but supportive health care team, mentors, and friend/family community has been clinically proven to improve relationships, future outlook, psychological/emotional/physical well-being, improved quality of life, and better adherence to treatments. Those with supportive communities have been shown to miss fewer appointments and have fewer episodes of relapse (9).