Diagnosis and classification

Bulimia nervosa is one of the two main eating disorders recognized in DSM-IV and ICD-10. The other is anorexia nervosa (see C.h.a.PteI..4,!.0,!.). Three features must be present to make a diagnosis of bulimia nervosa.

1. Recurrent episodes of 'binge eating' (defined below).

2. The regular use of extreme methods of weight control (e.g. highly restrictive dieting, self-induced vomiting, the misuse of laxatives and diuretics, or overexercising).

3. A characteristic set of attitudes to shape and weight, at the heart of which is the judging of self-worth in terms of shape and weight. These attitudes are expressed as an intense dissatisfaction with shape and weight, a fear of weight gain and fatness, and, in many cases, a pursuit of weight loss and thinness.

In addition to the three required diagnostic features, there is an exclusionary criterion. This is that the person must not meet diagnostic criteria for anorexia nervosa. In practice, this means that the patient must not fulfil the low-weight criterion for anorexia nervosa (a body mass index below 17.5). The principal diagnostic criteria for anorexia nervosa and bulimia nervosa are summarized in Table 1.

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Table 1 Principal diagnostic criteria for anorexia nervosa and bulimia nervosa

Both DSM-IV and ICD-10 acknowledge the existence of eating disorders other than anorexia nervosa and bulimia nervosa. These may be described as 'atypical eating disorders'.(6) They have been poorly characterized and little has been written about them. Many appear to be incomplete expressions of anorexia nervosa or bulimia nervosa (either in severity or form), but others are qualitatively different. In DSM-IV, all eating disorders other than anorexia nervosa and bulimia nervosa are placed in the single category 'eating disorder not otherwise specified'. In ICD-10, various additional eating disorder categories are recognized (e.g. atypical anorexia nervosa, atypical bulimia nervosa, overeating associated with other psychological disturbances), although these concepts have never been adequately defined or differentiated. Figure 1 illustrates the relationship between anorexia nervosa, bulimia nervosa, and the atypical eating disorders.

Bulimia Diagrams

Fig. 1 A Venn diagram illustrating the relationship between the diagnoses anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). (Reproduced with permission from C.G. Fairburn and G.T. Wilson (1993). Binge eating: definition and classification. In Binge eating: nature, assessment and treatment (ed. C.G. Fairburn and G.T. Wilson), pp. 3-14. Guilford Press, New York.)

In DSM-IV, a provisional new eating disorder diagnosis was introduced which is termed binge eating disorder. It is placed in an appendix designed for possible future diagnostic concepts. Patients with binge eating disorder have recurrent episodes of binge eating, like those seen in bulimia nervosa, but they do not fulfil the diagnostic criteria for either anorexia nervosa or bulimia nervosa. This is a controversial category about which much remains to be learned. (78)

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