Principles of managing bulimia nervosa

The primary goals of managing bulimia nervosa are first to reduce the number of episodes of binge eating and purging, or extreme weight control methods, and then to help the patient have a positive relationship with food and eating, by focusing on good psychosocial function and mental wellbeing. Patients are primarily managed in an outpatient setting with a healthcare professional with expertise in managing eating disorders, usually a psychologist.

Assessing for and managing medical complications can be lifesaving. Monitor patients with bulimia nervosa closely for metabolic consequences of purging behaviours, such as hypokalaemia and dehydration. Hypokalaemia is a common complication of purging behaviour and laxative abuse, and can lead to cardiac dysrhythmia. For information on the management of hypokalaemia, see here.

The Eating Disorders Examination Questionnaire (EDE-Q) (available via the Centre for Research on Eating Disorders at Oxford (CREDO) website) assesses severity of symptoms, which is relevant to accessing care through the Medicare Benefits Schedule, see here for current information.

Admit patients to hospital¹ who:

• are at risk of suicide
• are medically unwell
• have refractory symptoms to outpatient care.

If a pregnant patient with bulimia nervosa is frequently binge eating or purging (ie 3 or more times a week), refer them to a perinatal unit for specialist management.

There is a very high occurrence (over 90%) and a range of psychiatric comorbidities in patients with bulimia nervosa, including:

• major depression—most common
• anxiety disorders—particularly social anxiety disorder and posttraumatic stress disorder
• personality disorders
• substance use disorders.

If a comorbid psychiatric disorder is identified, refer to recommendations for the disorder and manage it concurrently. Substance abuse and deliberate self-harm need to be addressed first to enable a person with bulimia nervosa to engage in therapy.

Better outcomes are seen in patients with an early response to treatment (within the first weeks of treatment), no history of drug abuse or obesity, and in those with good interpersonal function. Approximately 50% of patients make a full recovery, 30% a partial recovery and 20% continue to be symptomatic after treatment.

It is preferable for bulimia nervosa to be in remission before pregnancy—otherwise pregnancy outcomes are poorer. Advise patients with bulimia nervosa to delay conception until their symptoms are well controlled. See here for advice on contraception, preconception planning and the use of psychotropics in females of childbearing potential.

For considerations in managing bulimia nervosa in:

• pregnancy, see here
• the postpartum, see here.

Useful resources are available from:

• Butterfly Foundation
• Centre for Clinical Interventions Resources for eating disorders
• The Victorian Centre of Excellence in Eating Disorders (CEED)
• Centre for Research on Eating Disorders at Oxford (CREDO), for outcome instruments and self-help resources
• Eating Disorders Families Australia (EDFA)
• Eating Disorders Victoria
• Lifeline (13 11 14)
• Headspace
• InsideOut Institute
• National Eating Disorders Collaboration
• Cooper P. Overcoming bulimia nervosa and binge eating. A guide to recovery. 3rd edition London: Robinson Press; 2009.
• Fairburn C. Overcoming binge eating. 2nd edition New York: The Guilford Press; 2013
• Schmidt U, Treasure J, Alexander J. Getting better bitE by bitE: A survival kit for sufferers of bulimia nervosa and binge eating disorders. 2nd edition London, New York: Routledge; 2016
• Treasure J, Smith G, Crane A. Skills-based learning for caring for a loved one with an eating disorder. 2nd edition London, New York: Routledge; 2017.