DSM bulimia nervosa Flashcards
(10 cards)
diagnostic criteria BN
- Criterion A: Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
Eating, in a discrete period of time an amount of food that is larger than what most individuals would eat in a similar period of time under similar circumstances.
A sense of lack of control over eating during the episode. - Criterion B: Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives or excessive exercise.
- Criterion C: The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months.
- Criterion D: Self-evaluation is unduly influenced by body shape and weight.
- Criterion E: The disturbance does not occur exclusively during episodes of anorexia nervosa.
It is also necessary to specify the state of the current remission:
- In partial remissions needs to be specified when 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 needs to be specified when after full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.
The current severity of BN also needs to be specified. The minimum level of severity is based on the frequency of inappropriate compensatory behaviours. The level of severity can be increased to reflect other symptoms and how functional disabled the person is:
- Mild: 1–3 episodes of inappropriate compensatory behaviours per week.
- Moderate: 4–7 episodes of inappropriate compensatory behaviours per week.
- Severe: 8–13 episodes of inappropriate compensatory behaviours per week.
- Extreme: 14 or more episodes of inappropriate compensatory behaviours per week.
Diagnostic features
An “episode of binge eating” is defined as eating, in a certain period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances. A “discrete period of time” refers to a limited period, usually less than 2 hours. A single episode of binge eating does not need to be restricted to one setting, which means that for example it could start in a restaurant and continue at home.
The type of food consumed during binges varies Binge eating appears to be characterised more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. However, during binges, individuals tend to eat foods they would otherwise avoid.
Binge eating usually occurs in secrecy. This is because individuals with BN are typically ashamed of their eating problems and try to hide their symptoms.
Most often what precedes an episode of bingeing has a negative affect. Other antecedents can be interpersonal stressors, dietary restraint, negative feelings that are related to body weight, shape and food as well as boredom. Bingeing might lead to minimising the negative feelings of these antecedents in the short term but negative self evaluation and dysphoria can often be delayed consequences.
Many individuals with bulimia nervosa employ several methods to compensate for binge eating. Self-induced vomiting, a type of purging behaviour, is the most common inappropriate compensatory behaviour. The immediate effects of vomiting include relief from physical discomfort and reduction of fear of gaining weight.
Excessive emphasis on their body weight and shape is very important for individuals with BN to determine their self-esteem.
Associated features
Individuals with BN typically are within the normal weight or overweight range. Between binges, individuals with BN, typically restrict their total caloric consumption and avoid foods that they perceive to be fattening or likely to trigger a binge.
Menstrual irregularity or amenorrhea often occurs among women with bulimia nervosa; it is uncertain whether such disturbances are related to weight fluctuations, to nutritional deficiencies, or to emotional distress. Rare but potentially fatal complications include esophageal tears, gastric rupture, and cardiac arrhythmias.
Prevalence
The 12-month prevalence of bulimia nervosa in females is 1- 1.5%. The point prevalence is highest among young adults since the disorder peaks in older adolescence and young adulthood. It is far less common in males. The female to male ratio is 10:1.
The reported prevalence of bulimia nervosa is highest in populations residing in high-income industrialised countries.
- De levensprevalentie is 0.9-3% met een beginleeftijd van 16-17 jaar.
- Het sterftecijfer (CMR) is 2% per decennium. Het risico op levenssuïcidaliteit en suïcidale pogingen zijn veel hoger dan anorexia nervosa.
10-15% hebben een kruising van boulimia nervosa naar anorexia nervosa, zij zullen ook weer terugvallen naar boulimia nervosa of meerdere kruisingen ervaren. - Het komt ongeveer evenveel voor in alle geïndustrialiseerde landen, de meesten zijn wit.
- Het komt veel vaker voor bij vrouwen.
Development and course
Bulimia nervosa commonly begins in adolescence or young adulthood. An onset before puberty or after 40 is uncommon. Binge-eating frequently begins during or after an episode of dieting to lose weight. Experiencing multiple stressful life events also can precipitate onset of bulimia nervosa.
Disturbed eating behaviour persists for at least several years in a high percentage of clinical samples. The course may be chronic or intermittent, with periods of remission in between.
There is a significant elevated risk for mortality with a mortality rate of almost 2% per decade.
In a minority of the cases (10-15%) there is a diagnostic crossover from initial bulimia nervosa to anorexia. Individuals that do experience this crossover often revert to bulimia nervosa after some time.
Risk and prognostic factors
- Temperamental: Factors associated with increased risk for BN are weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, and generalized anxiety disorder (GAD) in childhood.
- Environmental: The internalization of a thin body ideal increases the risk for developing weight concerns, and this increases the risk for BN. Sexual or physical abuse in childhood also increases the risk for the development of BN.
- Genetic and physiological: Childhood obesity and early pubertal maturation increase the risk for BN. And familial transmission of BN can also be present. There is some evidence for genetic vulnerabilities.
- Course modifiers: The severity of psychiatric comorbidity predicts worse long-term outcome of BN.
Diagnostic markers
No specific diagnostic test for bulimia nervosa currently exists. However, several laboratory abnormalities may occur as a consequence of purging and may increase diagnostic certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which can provoke cardiac arrhythmias), hypochloremia, and hyponatremia.
Inspection of the mouth may reveal significant and permanent loss of dental enamel
Functional Consequences of Bulimia Nervosa
Individuals with bulimia nervosa may exhibit a range of functional limitations associated with the disorder. A minority of individuals report severe role impairment, with the social-life domain most likely to be adversely affected by bulimia nervosa.
Differential diagnosis
- Anorexia nervosa, binge-eating/purging type: Individuals whose binge-eating behaviour occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, binge-eating/purging type, and should not be given the additional diagnosis of bulimia nervosa. The diagnosis of BN can only be given when the criteria have been met for at least 3 months.
- Binge-eating disorder: When people binge-eat but do not do regular compensatory behaviours.
- Kleine-levin syndrome: In this disorder there is disturbed eating behaviour, but the characteristic psychological features of BN are not present.
- Major depressive disorder with atypical features: overeating is common in MDD, but with this disorder individuals do not engage in compensatory behaviour and are not excessively concerned about their body shape and weight.
- Borderline personality disorder: binge-eating is included in the impulsive behaviour criterion that is a part of borderline personality disorder. If the criteria for both borderline and BN are met, both diagnoses should be given.
comorbidity
Comorbidity with mental disorders is common in individuals with bulimia nervosa, with most experiencing at least one other mental disorder and many experiencing multiple comorbidities. There is an increased frequency of depressive symptoms (e.g., low self-esteem) and bipolar and depressive disorders (particularly depressive disorders) in individuals with bulimia nervosa. There may also be an increased frequency of anxiety symptoms or anxiety disorders.
The lifetime prevalence of substance use disorder, particularly alcohol use disorder or stimulant use disorder, is at least 30% among individuals with bulimia nervosa. Borderline disorder can also be comorbid.
