The identification of patients with bulimia nervosa is not difficult so long as the diagnosis is considered. This is important because the shame that characterizes the disorder leads many people to delay seeking help—the average delay between onset and presentation is about 5years—and when they do present for treatment, some do so indirectly. Thus they may complain of depression, substance abuse, menstrual disturbance, or gastrointestinal symptoms, rather than the eating disorder itself. The best policy is for psychiatrists always to keep in mind the possibility of bulimia nervosa when assessing female patients aged between 16 and 35years. Negative responses to the following two questions should suffice to exclude the disorder.
1. Do you have any problems with your eating?
2. Do you have any problems controlling your eating, i.e. problems with binge eating?
Patients who present directly complain of having lost control over eating and their assessment is generally straightforward.
The best established measure of eating disorder features is the Eating Disorder Examination. (53) This interview is widely regarded as the 'gold standard' measure of eating disorders/54» and it may be used either for routine clinical assessment or for research purposes. It defines all key terms and generates operational eating disorder diagnoses. Various self-report questionnaires are available but they provide a more basic level of assessment and they cannot be used to make a clinical diagnosis. The leading self-report measures are the Eating Disorder Inventory (55) and the self-report version of the Eating Disorder Examination. (56>
No assessment is complete without weighing the patient. This needs to be done with considerable sensitivity because of these patients' concerns about their weight. A physical examination is not essential unless the patient is underweight (or there are other medical indications), nor are laboratory tests required except in those cases in which there is reason to suspect that there might be fluid or electrolyte disturbance.
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