Bulimia nervosa

Bulimia nervosa is often hidden behind a normal weight, so the exam tests whether the counselor spots the binge-compensation cycle and its medical risks.

Criteria at exam depth (paraphrased):

• Recurrent binge eating: eating, in a discrete period, an amount clearly larger than most people would, with a sense of loss of control.
• Recurrent inappropriate compensatory behavior to prevent weight gain: self-induced vomiting, laxatives, diuretics or other medications, fasting, or excessive exercise.
• Binges and compensatory behavior both occur at least once a week for 3 months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.
• Severity by compensatory episodes per week: mild 1–3, moderate 4–7, severe 8–13, extreme 14 or more.
• Remission specifiers: partial and full.

Hinge differentials:

• Anorexia nervosa, binge-eating/purging type — significantly low weight; bulimia typically occurs at normal or above-normal weight.
• Binge-eating disorder — no regular compensatory behavior.
• Major depression with increased appetite — overeating without compensatory behavior or overvaluation of shape.
• Borderline personality disorder — binge eating can be one of several impulsive behaviors; diagnose both when criteria are met.

On the NCMHCE: Purging carries medical risk: electrolyte imbalance (especially low potassium) and cardiac arrhythmia, dental erosion, swollen salivary glands, esophageal injury, and calluses on the back of the hand from induced vomiting (Russell's sign). Refer for medical evaluation and lab monitoring, and watch these physical clues on the mental status exam. Screen for suicide risk, self-harm, and substance use, which commonly co-occur. CBT for eating disorders (CBT-E) is the best-supported psychotherapy; it targets dietary restraint, the binge-purge cycle, and the overvaluation of shape and weight (for example, "If my body looked right, everything would fall into place"). Family-based treatment is used for adolescents. Shame and secrecy are common, so a nonjudgmental stance aids disclosure. Antidepressant medication can be a referral topic for medical evaluation.

Clinical Pearl: Bingeing plus compensation at least weekly for 3 months, with self-worth tied to shape; weight is usually normal or above normal. Purging means medical monitoring.