WORKING WITH FAMILIES INSTITUTE

Bulimia
Nervosa:
Purging Patients’
and Families’
Misconceptions

Anu Joneja, MD, BSc, CCFP

The Working With Families Institute, Department of Family & Community Medicine, University of Toronto
 WORKING WITH FAMILIE S INSTITUTE

In today’s world, families are under increasing stress, from financial and time constraints, to family breakdown,
substance abuse, and threats of violence. Family physicians are seeing an increase in psychosocial issues such as
anxiety and stress-related disorders, often co-existing with and complicating medical problems such as diabetes
or pneumonia. The psychosocial issues are often more difficult to diagnose and manage than are the medical
problems—and all take place in the family context. Very often, the family is the key to dealing effectively with the whole
spectrum of complaints, requiring a psychosocial assessment. In the crowded family medicine curriculum, this vital
area of knowledge and skill is often ignored in favour of more clear-cut procedural skills.
To educate family physicians about dealing with families, a group of family medicine educators, practitioners and
mental health professionals affiliated with the Department of Family and Community Medicine at the University Of
Toronto founded the Working with Families Institute (WWFI) in 1985. The WWFI has developed various training
experiences for trainees and practising physicians.
Goals
The goal of these modules is to provide a learning resource for physicians dealing with common medical and
psychosocial issues that have an impact on families. The modules seek to bridge the gap between current and best
practice, and provide opportunities for physicians to enhance or change their approach to a particular clinical problem.
The modules have been written by a multidisciplinary team from the Faculty of Medicine, University of Toronto. Each
module has been peer-reviewed by external reviewers from academic family medicine centres across Canada. The
approach is systemic, emphasizing the interconnectedness of family and personal issues and how these factors may
help or hinder the medical problems. The topics range from postpartum adjustment to the dying patient, using a
problem-based style and real case scenarios that pose questions to the reader. The cases are followed by an
information section based on the latest evidence, case commentaries, references and resources.
How to Use the Modules
The modules are designed for either individual learning or small group discussion. We recommend that readers
attempt to answer the questions in the case scenarios before reviewing the case commentaries or reading the
information section.
The editors welcome feedback on these modules and suggestions for other modules. Feedback can be directed to Dr.
Watson at [email protected].
Acknowledgements
The WWFI is grateful to the Counselling Foundation of Canada for its generous educational grant in support of this
project. The editors also thank Iveta Lewis (Librarian-DFCM) Brian Da Silva (IT consultant-DFCM), and Danielle
Wintrip (Communications Coordinator-DFCM) for their valuable contributions to this project.
In addition, we thank our editorial advisory group including Ian Waters, MSW, Peter Selby MD, Margaret McCaffery,
and William Watson, MD.
We also acknowledge the work of the Practice-based Small Group Learning Program of the Foundation for Medical
Practice Education, on which these modules are modelled.

Bill Watson
Margaret McCaffery
Toronto, 2014

Working With Families Institute, 2014 2

 WORKING WITH FAMILIE S INSTITUTE

Bulimia Nervosa: Purging Patients’ and Families’ Misconceptions

Authors:
Anu Joneja, MD, BSc, CCFP
Lecturer, Department of Family & Community Medicine
University of Toronto
Toronto, ON

Reviewers:
Patricia Windrim, MD, CCFP
Assistant Professor, Department of Family and Community Medicine
University of Toronto;
Staff Physician, St. Michael’s Hospital
Toronto, ON

Zoe Francis Costa-von Aesch, MD

Resident, Department of Family and Community Medicine
University of Toronto
Toronto, ON

Editors:
William J. Watson, MD, CCFP, FCFP
Margaret McCaffery, Canterbury Communications

Working With Families Institute, 2014

Chair: William J. Watson, MD, CCFP, FCFP

Associate Professor, Department of Family & Community Medicine
and the Dalla Lana School of Public Health
University of Toronto

3 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

CONTENTS

SUMMARY .......................................................................................... 5

OBJECTIVES ...................................................................................... 5
Key Features .............................................................................. 5
Core Competencies .................................................................... 5

CASE STUDY ..................................................................................... 6

INFORMATION POINTS ..................................................................... 8

Epidemiology .............................................................................. 8
Diagnosis ................................................................................... 8
Clinical Features ......................................................................... 8
Assessment ................................................................................ 9
Comorbid Conditions ................................................................ 10
Treatment ................................................................................. 11

CASE COMMENTARY ...................................................................... 12

REFERENCES .................................................................................. 15

RESOURCES .................................................................................... 17

Working With Families Institute, 2014 4

SUMMARY
Articles on weight loss and images of underweight models and actresses are
everywhere. Adolescent girls are particularly vulnerable to these messages and
images, and to various other environmental influences. Eating disorders
therefore are a significant cause of morbidity and mortality within this
population. These disorders frequently involve complex psychosocial issues,
and their severity is often influenced by significant family events such as
divorce or death. Individuals with a family history of alcoholism, major
depression, or sexual or physical abuse are at increased risk of developing
eating disorders. The family should not, however, be viewed as the precipitator
of eating disorders. Rather, the family is intricately involved in a complex
disorder, and both require and provide various levels of support, depending on
the circumstances. Because of increasing wait times for limited spots in eating
disorder clinics, family physicians (FPs) must be comfortable diagnosing and
managing bulimia nervosa. Management often involves coordinating a
multidisciplinary team of psychiatrists, psychologists, dietitians, community
support agency professionals, and other available professionals. At the same
time, the FP must provide ongoing counselling and support to both the patient
and the family.

OBJECTIVES
After completing this module, you will be able to:
1. review the diagnostic criteria for bulimia nervosa.
2. discuss assessment techniques for bulimia nervosa.
3. recognize the treatment options for bulimia nervosa and how to implement
them.

Key Features
1. Bulimia is a complex, often long-term condition, and its development is
frequently influenced by family relationships and events.
2. The FP’s role is to provide timely diagnosis and treatment, to work as part
of a multidisciplinary team, and to provide long-term support to patients
and their families.

Core Competencies
The core competencies addressed relate to the FP’s roles as a communicator, a
diagnostician, and a manager:
1. Taking a history focusing on the patient’s experience with bulimia,
incorporating the effect of major life events and the patient’s family
dynamic
2. Exploring the effect of the patient’s cultural and social context on the
presentation of bulimia and applying an understanding of this context to the
development of a treatment plan
3. Understanding the various screening tools available to assess the risk of
eating disorders

5 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

CASE STUDIES

Case 1: Annie
Annie, age 20, visits for her annual well-patient visit. She is an international
student from Korea who has been studying at a Toronto university for the past
two years. While you are weighing Annie, you notice that she is visibly
distressed. She asks whether her weight is normal. On further questioning, you
suspect that she may have an eating disorder.

Annie is the elder of two daughters and feels tremendous pressure to conform to
the “normal” appearance for women in her culture. She states that she is unable
to find clothes that fit her when she is home in Korea and feels constant
pressure from her mother to lose weight, despite her normal body mass index.
During weekly phone calls, her mother typically asks, “Are you still fat?” Her
mother has “never been happy” with Annie’s appearance, and Annie feels
ashamed that she is not able to fit the ideal image her mother expects. Annie
states that she tries to maintain a restrictive diet during the week but struggles to
control her appetite, which leads to episodes of overeating. Greatly distressed
about gaining weight, she induces vomiting after eating.

Annie typically buys ice cream, cookies, and candy bars from the corner store
on the way home from studying at the library. During a one-hour period, she
consumes her purchases, as well as any leftover desserts in her refrigerator.
Then she induces vomiting. She states that these episodes occur most frequently
during exam periods, as well as before seeing family members.

Annie is ashamed of her “disgusting habit” and very unhappy about her
appearance. She admits to feeling sad most days. She often compares herself
with other women and is very self-conscious. She does not like going out to eat
with her friends, as she feels people are judging her eating and appearance. As a
result, she has few close friends and often socially isolates herself. She has not
told anyone about her eating disorder.

 What further assessment is required?

 For what comorbid conditions must you screen?
 What treatment options are available?
 How do you counsel Annie about her eating disorder?
 What other specific historical information do you obtain from Annie?
 How do you help Annie deal with her family pressures?

Case 2: Rachel
Paula, a 37-year-old single mother, comes in for her regular follow-up
appointment. You have been treating her depression over the past year with an
SSRI antidepressant as well as regular counselling. She has had problems
coping not only with the recent separation from her husband, but also with the
stressors associated with being a single mother. She expresses her concern over
the recent change in behaviour of her 16-year-old daughter Rachel who is also a
patient of yours. She describes Rachel as having changed from her previous

Working With Families Institute, 2014 6

 happy-go-lucky personality to moody, irritable and distant. You ask Paula to
make an appointment for Rachel so you can assess her.

The following week, Rachel comes in. You last saw her two years ago for her
tetanus-diphtheria booster. She is very quiet and reserved initially and answers
many of your questions with one-word answers. She is an only child and attends
the local public high school. She states that she no longer likes going to school.
As she begins to feel more comfortable with you, she begins to open up about
the reasons. She states that she was being teased about being “fat” earlier in the
year and began severe dieting to lose weight. She did initially lose weight but
was finding that her food cravings were overwhelming. She found that she
would “lose control” and consume large volumes of “fattening” foods. The guilt
and worry about gaining weight would drive her to vomit after eating, up to
three times a day. She has not told anyone about her eating patterns.

 Does having her mother as a patient undermine your therapeutic

relationship with Rachel?
 What other information would you like to know about the family?
 How would you treat Rachel’s disordered eating?

7 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

INFORMATION POINTS

Epidemiology
1. Approximately 90% of cases of bulimia nervosa are in females; the
estimated lifetime prevalence among young women is 1% to 3%.1,2 Bulimia
nervosa typically begins in adolescence or early adulthood, and has a
median age of onset of 20 years.3 It may be chronic or intermittent, with
symptoms and remissions fluctuating over the years. Families have
difficulty identifying this disorder because of patients’ extreme secrecy and
body weights that are usually within the normal range.4 Family physicians
therefore must provide family members with adequate information about
the symptoms, course, and treatment.

Diagnosis
2. In order for a diagnosis of bulimia to be made, all the following DSM-IV
criteria must be met: 5
 Recurrent episodes of binge eating, which is defined as the
consumption of an unusually large amount of food in a discrete period.
Patients feel that they cannot control their eating during these episodes.
Recurrent inappropriate compensatory behaviour is used to prevent
weight gain.
 Binge eating and inappropriate compensatory behaviours occur at least
twice a week for three months.
 The patient’s self-evaluation is unduly influenced by body shape and
weight.
 The disturbance does not occur exclusively during an episode of
anorexia nervosa.

Clinical Features
3. Interpersonal stressors and dysphoria can trigger the binge-purge cycle. The
typical behavioural sequence is calorie restriction, and then binge eating
followed by self-induced vomiting. Objectively, a binge is equivalent to at
least two meals or approximately 2000 kcal.6,7

This consumption must be considered in view of the situational context.

For example, this amount of food may be excessive for a typical meal but
normal during a celebration. Subjectively, the patient may consider the
amount of food consumed excessive because of associated feelings of loss
of control over eating. This loss of control is not absolute, as individuals
will stop bingeing if someone interrupts them unexpectedly.

Features often associated with binge eating include eating more rapidly
than normal, eating until uncomfortably full, eating large amounts when not
hungry, eating alone because of embarrassment, feeling disgusted, feeling
depressed, or feeling very guilty because of eating. Foods typically eaten
often include high-calorie sweets, but patients do not appear to crave any

Working With Families Institute, 2014 8

 specific nutrient. Between binges, patients often eat low-calorie food
unlikely to trigger a binge.4,7,8

4. Self-loathing, remorse, and dysphoria often follow a binge. Patients are

often preoccupied with their weight and use it to determine their self-worth.
This preoccupation is manifested by repeated weighing, pinching of body
areas, measuring of body parts, mirror gazing, and comparisons with
others’ bodies.

5. The two subtypes of bulimia are purging and non-purging. The purging
type is characterized by self-induced vomiting and misuse of laxatives,
diuretics, diet pills, thyroid preparations, enemas, or other agents. The
vomiting is most commonly self-induced; patients use their fingers to
stimulate the gag reflex. Patients may also ingest ipecac syrup, and chronic
use can result in cardiac and skeletal myopathies. The non-purging subtype
of bulimia is characterized by fasting or excessive exercise.4,7,8

6. The medical complications of bulimia are related to the mode and

frequency of purging. Key signs of compensatory behaviour are evident
during physical examination, and include erosion of dental enamel,
hypertrophy of the parotid glands, and calluses on the knuckles (Russell’s
sign). Other common physical signs are orthostatic hypotension,
bradycardia, and dry skin. Hypothermia, cardiac murmur (mitral valve
prolapse), or other cardiac arrhythmias may also be evident. Regular
vomiting can result in dehydration, hypokalemia with associated
electrocardiographic changes, hypochloremia, and metabolic alkalosis.
Frequent vomiting may lead to gastroesophageal reflux or Mallory-Weiss
tears. Dyspepsia is common. Patients may also suffer from severe
constipation as a result of myenteric plexus damage from laxatives.8,9

Assessment
7. Currently, routine screening is not the standard of care. However, screening
should be considered in all college-aged women.8 The five questions on the
SCOFF questionnaire can be used as a screening tool questionnaire:
 Do you make yourself Sick because you feel uncomfortably full?
 Do you worry you have lost Control over how much you eat?
 Have you recently lost more than One stone (6.35 kg or 14 lb) in a
three-month period?
 Do you believe yourself to be Fat when others say you are too thin?
 Would you say Food dominates your life?

An answer of “yes” to two or more questions is associated with 100%

sensitivity and 87.5% specificity for an eating disorder diagnosis.10

The Eating disorder Screen for Primary care (ESP) is an alternative

screening tool:
 Are you satisfied with your eating pattern? (“No” is abnormal.)
 Do you ever eat in secret? (“Yes” is abnormal.)
 Does your weight affect the way you feel about yourself? (“Yes” is
abnormal.)

9 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

  Have any members of your family suffered with an eating disorder?
(“Yes” is abnormal.)
 Do you currently suffer with or have you ever suffered in the past with
an eating disorder? (“Yes” is abnormal.)

Two abnormal responses to the ESP have 100% sensitivity and 71%
specificity for an eating disorder diagnosis.11

8. Laboratory testing should include a complete blood count, measurement of

electrolytes, creatinine, blood glucose, and thyroid-stimulating hormone, as
well as liver-function tests and urinalysis. Electrocardiography is indicated
for patients with bradycardia or electrolyte abnormalities. Dual-energy X-
ray absorptiometry scanning should be considered for patients who have
had amenorrhea for more than six to 12 months. In addition, testing for
pregnancy and measurements of luteinizing hormone, follicle-stimulating
hormone, prolactin, and estradiol may be indicated to rule out other
potential causes of amenorrhea.8,9,12

9. During history-taking, the FP should ask about the patient’s highest and
lowest weights as an adult, patterns of weight fluctuations, desired weight,
frequency of self-weighing, food intake patterns when the patient is not
binge eating, and current and past eating disorder symptoms. Obtain more
information on binge-eating behaviour, including frequency, types and
amounts of food eaten, and whether the patient feels she or he can control
eating during binges. This information will enhance your understanding of
the compensatory behaviour and the degree to which the patient’s self-
esteem depends on body weight and shape.

10. Determine how much the family knows about the eating disorder, how they
perceive it, when they found out, who has been most involved, and their
overall understanding. This information permits a realistic appraisal of how
different family members may participate in the patient’s recovery.

11. Especially for younger patients, assess active issues at home, such as
marital problems or other family members’ illness. The focus is not on
blaming family members, but on examining how these issues are affecting
everyone in the family, including the patient.13

12. Assess the patient’s desire for family involvement, as some may wish to
avoid any support from the family and to have their confidentiality
maintained. Ethical issues arise if a minor child’s right to confidentiality
may be outweighed by the need to inform a parent or guardian. In such
cases, consider many factors, such as competence, age, maturity, and
potential for harm.14

Comorbid Conditions
13. Bulimia is often accompanied by suicidality, anxiety disorders, major
depression, specific phobias, substance use disorders, impulse control
disorders, personality disorders, or—commonly—a combination of these.
Screening for these conditions is therefore recommended.1,7,8

Working With Families Institute, 2014 10

 Treatment
14. Cognitive behavioural therapy (CBT) is the treatment of choice, as it
focuses on the features that maintain the binge-purge cycle, rather than on
factors that led to its initial development.2 A recent article by Murphy et al.
provides a detailed guide to CBT for patients with eating disorders.15 It
outlines the four stages of CBT including educating and engaging the
patient, self-monitoring, weekly weighings, establishing “regular eating”,
addressing the over-evaluation of weight, and identifying other domains for
self-evaluation.

15. If the patient is willing, family and friends must be involved in treatment.
Their involvement provides support so that the patient can make necessary
changes, and also can minimize negative comments about the patient’s
eating or appearance. A study has shown that, in comparison with
individual therapy, parental involvement in family-based therapy doubled
the percentage of teens who were able to abstain from binge eating and
purging after six months.16

16. A combination of pharmacotherapy and psychotherapy is more efficacious

than either alone.17

17. Pharmacotherapy should involve the following approaches:18,19

 First-line treatment with the selective serotonin-reuptake inhibitor
(SSRI) fluoxetine
 Second-line treatment with a different SSRI (e.g., citalopram,
fluvoxamine, or sertraline) for patients who do not tolerate or respond
to fluoxetine
 Third-line treatment, in order of preference, with a tricyclic
antidepressant (e.g., desipramine, imipramine, or nortriptyline),
topiramate, trazodone, or a monoamine oxidase inhibitor (e.g.,
phenelzine)
 Avoidance of bupropion because of its association with an increased
frequency of seizures in patients with bulimia20

18. With nutritional rehabilitation, the aim is to restore a structured and

consistent meal pattern, typically three meals and two snacks a day.21 A
registered dietitian can help with nutritional education and meal planning.
The Provincial Specialized Eating Disorders Program has a useful video to
help families provide meal structure and support patients with eating
disorders.22

19. Consider referring families to family support groups. These not only
provide support, but encourage family members to be realistic about the
degree to which they will be able to influence the recovery process.

11 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

CASE COMMENTARIES

Case 1: Annie

 What further assessment is required?

 For what comorbid conditions must you screen?
 What treatment options are available?
 How do you counsel Annie about her eating disorder?

You conduct the initial evaluation interview. Annie’s blood test and ECG
results are normal, and she declines pharmacotherapy. You identify a history of
depression, but note no current suicidality and conclude that CBT is
appropriate. She begins seeing you twice a week for the next four weeks. Annie
begins keeping a diary to monitor her food consumption, inappropriate
compensatory behaviours, and thoughts and feelings while eating to help
increase her awareness and understanding of her binge/purge triggers. You
educate her about bulimia and “regular eating”, where you ask her to eat three
planned meals plus two or three planned snacks with no compensatory
behaviour. She also sees a dietitian and upon your recommendation. The
dietitian helps her establish a regular eating plan, and you weigh her weekly.

 What other specific historical information do you obtain from Annie?

On further evaluation, you learn more about Annie’s complex relationship with
her mother. Growing up, her mother was verbally and occasionally physically
abusive. Her mother upheld an extremely high standard for “everything,”
ranging from appearance to academic performance.

Growing up, Annie could not communicate with her mother. She felt she did
not “measure up”; now she believes she is a constant disappointment and a large
amount of guilt is associated with this belief. She states that she “just isn’t
trying hard enough” when you ask whether she feels her mother’s expectations
are reasonable. Annie continues to hold her mother in high esteem and has a
constant need for her approval.

Annie also states that her father is “always working.” As a result, she does not
have a close relationship with him.

 How do you help Annie deal with her family pressures?

Overcoming the communication boundary is an overwhelming goal for Annie

initially. With her family being in Korea, face-to-face family counselling is not
possible. Annie does not consent to a telephone session with her family, stating
that she does not want to put her mother “on the spot.” However, the
relationship difficulties with her mother appear to be at the root of her low self-
esteem and severe self-evaluation based on weight. After four weeks, Annie is
ready to begin addressing the issues with her mother. The conversation begins

Working With Families Institute, 2014 12

 with Annie asking her mother if she ever felt pressure to be thin. Annie is
surprised when her mother opens up and says she suffered from bulimia because
of similar verbal assaults from her own mother. This admission is the first time
her mother has demonstrated vulnerability. It allows Annie to begin sharing her
experiences and feelings. Specifically, it permits Annie to begin building a
supportive rather than judgmental relationship with her mother. With her new
understanding and support from her mother, Annie is able to reappraise her
frame of mind.

Over the following eight weeks, you continue to see Annie weekly. During
these sessions, you help Annie identify the over-importance of weight in her
self-evaluation. You explore other, nonperformance-related domains for self-
evaluation. Annie begins playing the piano—a hobby she used to enjoy—and
starts volunteer work. She feels very positive about this work. Annie also
identifies during appointments with you that she discounts her positive qualities
and overgeneralizes her failures. Becoming more cognizant of this allows her to
begin developing a more balanced view of herself.

In addition, Annie continues to rebuild the relationship with her mother. She
also begins to reconnect with her sister. They were close when they were
younger, but because of Annie’s shame and guilt, she progressively distanced
herself from her sister. Annie begins to feel comfortable with her sister and to
confide in her, and receives a great deal of support from the relationship.

Case 2: Rachel

 Does having her mother as a patient undermine your therapeutic

relationship with Rachel?

With adolescent patients, it is important to remind them of the doctor-patient

confidentiality that exists as they often see the family physicians as “their
parent’s doctor.” Without this understanding, it is often difficult to build a
therapeutic relationship in which the patient feels comfortable enough to open
up and discuss personal issues.

 What other information would you like to know about the family?

With ongoing visits, Rachel reveals that her parent’s divorce has been
particularly difficult for her. She now sees her father only once a week and feels
it difficult to maintain the close relationship she had with him, given the time
limitations. She felt her father often lightened the mood around the house. She
feels her mother’s depression makes being at home “a downer” and blames her
mother for the dissolution of the marriage, stating that “even I don’t like being
at home.” Rachel feels guilt in thinking these thoughts and she admits that her
“mom isn’t depressed on purpose.” She feels that she has lost control over how
her day turns out. She describes having a good day at school, only to come
home to her mom crying. She states she does not know how to make her mother
feel better and thinks that if she was thinner, her mom would be happier.

13 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

 Rachel agrees to tell both parents about her bulimia. Paula finds the bulimia
diagnosis difficult to accept at first and feels increased guilt about her
depression having caused it. With time, the focus of attention shifts from blame
to understanding how the situation was affecting everyone in the family. A plan
is made including both parents in the process of recovery, mainly through
family counselling sessions. Both her parents are consciously providing more
support and empathy to Rachel, without any blame. The family relationship
dynamics are addressed with Rachel having the opportunity to express her
concerns about the effects of her parents’ separation and her mother’s
depression. Her father is very supportive and understanding, and makes a
mutually accepted plan of increased “quality time”.

 How would you treat Rachel’s disordered eating?

CBT is initiated initially twice weekly for four weeks. During these sessions,
her over-evaluation of weight and binge-triggering moods are identified as
targets for treatment. Rachel begins self-monitoring her eating, thoughts and
feelings to help increase her awareness and understanding of what triggers her
desire to binge/purge. You educate her about bulimia and “regular eating”,
where she is asked to eat three planned meals plus two or three planned snacks
with no compensatory behaviour. Strategies are identified to help achieve these
goals, such as eating meals with her mother and planning to go for a walk with
her immediately after completing the meal, to distract her from the urge to binge
and decrease the ability to binge by physically leaving the house.

The session frequency is decreased to once weekly after success in the first
month. During the subsequent sessions, her over-evaluation of shape and
weight are addressed. Becoming more aware of how much importance Rachel
is putting on her weight allows her to begin switching the focus to other
domains of her life. She began to focus more time on school and playing tennis
again. By helping Rachel re-establish her other interests, she is given other
domains for self-evaluation.

You ask Rachel to monitor her body-checking behaviour. You educate her
about the negative effects of the constant scrutiny involved in repeated body-
checking and comparisons to an unrealistic ideal. Triggers to her feelings of
body dissatisfaction are identified to be mainly negative moods. Alternate
coping strategies are examined to deal with these moods, such as writing in a
journal or calling a friend.

With further success, three final appointments are made two weeks apart, in
which a personalized plan is made. This plan focuses on further decreasing
body-checking, continuing to identify negative moods and apply alternative
coping methods, and maintaining open communication with her parents.15

The high prevalence of bulimia makes it crucial for family physicians to detect
and manage the condition early. Family physicians need to be aware of the
resources available in their communities and must increase their comfort levels
in diagnosing and managing bulimia.

Working With Families Institute, 2014 14

REFERENCES

1. Hay PJ, Bacaltchuk J. Extracts from “Clinical Evidence”: bulimia nervosa.

BMJ. 2001;323:33-7.
2. Mitchell JE, Agras S, Wonderlich S. Treatment of bulimia nervosa: where
are we and where are we going? Int J Eat Disord. 2007;40:95-101.
3. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates
of eating disorders in the National Comorbidity Survey Replication. Biol
Psychiatry. 2007;61(3):348-358
4. Field AE, Camargo CA Jr, Taylor CB, Berkey CS, Frazier AL, Gillman
MW, Colditz GA. Overweight, weight concerns, and bulimic behaviors
among girls and boys. J Am Acad Child Adolesc Psychiatry. 1999;38:754-
760.
5. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders. 4th ed. Washington, DC: American Psychiatric
Association; 2000.
6. Agras WS. Treatment of eating disorders. In: Schatzberg AF, Nemeroff CB,
eds. The American Psychiatric Publishing Textbook of
Psychopharmacology. 4th ed. Washington, DC: American Psychiatric
Publishing; 2009. p. 1231.
7. Devlin MJ, Jahraus JP, DiMarco ID. Eating disorders. In: Levenson JL, ed.
The American Psychiatric Publishing textbook of psychosomatic medicine.
2nd ed. Washington, DC: American Psychiatric Publishing; 2011. p. 305.
8. Mehler PS. Bulimia nervosa. N Engl J Med. 2003;349:875-81.
9. Committee on Adolescence and American Academy of Pediatrics.
Identifying and treating eating disorders. Pediatrics. 2003;111:204-211.
10. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a
new screening tool for eating disorders. BMJ. 1999;319:1467-1468
11. Cotton MA, Ball C, Robinson P. Four simple questions can help screen for
eating disorders. J Gen Intern Med. 2003;18(1):53-56.
12. Zipfel S, Seibel MJ, Lowe B, Beumont PJ, Kasperk C, Herzog W.
Osteoporosis in eating disorders: a follow-up study of patients with
anorexia and bulimia nervosa. J Clin Endocrinol Metab. 2001;86:5227-33.
13. Woodside DB, Shekter-Wolfson L. Families and eating disorders [Internet];
2003 [cited 2013 Feb 15]. Available from: http://nedic.ca/families-and-
eating-disorders
14. Wheeler AM, Bertram B. The counselor and the law: a guide to legal and
ethical practice. 6th ed. Alexandria, VA: American Counseling Association;
2012.
15. Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral
therapy for eating disorders. Psychiatr Clin North Am. 2010;33:611-27.
16. Le Grange D, Crosby RD, Rathouz PJ, Leventhal BL. A randomized
controlled comparison of family-based treatment and supportive

15 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions

 psychotherapy for adolescent bulimia nervosa. Arch Gen Psychiatry. 2007
Sep;64(9):1049-56.
17. Palmer B. Epidemiology, diagnosing and assessing eating disorders.
Psychiatry. 2008;7(4):143-6.
18. Broft A, Berner LA, Walsh BT. Pharmacotherapy for bulimia nervosa. In:
Grilo CM, Mitchell JE, eds. The treatment of eating disorders: a clinical
handbook. New York, NY: Guilford Press; 2010. p. 388.
19. Shapiro JR, Berkman ND, Brownley KA, Sedway JA, Lohr KN, Bulik CM.
Bulimia nervosa treatment: a systematic review of randomized controlled
trials. Int J Eat Disord. 2007;40:321-326.
20. Horne RL, Ferguson JM, Pope HG Jr, Hudson JI, Lineberry CG, Ascher J,
Cato A. Treatment of bulimia with bupropion: a multicenter controlled trial.
J Clin Psychiatry. 1988;49:262-6.
21. American Psychiatric Association. Treatment of patients with eating
disorders. 3rd ed. Am J Psychiatry. 2006;163(7 Suppl):4-54.
22. The Provincial Specialized Eating Disorders Program for Children and
Adolescents. Eating disorders meal support: helpful approaches for
families; 2012 [cited 2013 Sep 8]. Available from:
http://www.youtube.com/watch?v=pPSLdUUlTWE&list=FLGHwOGU4H
VQi4ImFfYsItJg&index=1

Working With Families Institute, 2014 16

RESOURCES

1. Books for Patients and Families

Alexander-Mott L, Lumsden DB. Understanding eating disorders. Washington,
DC: Taylor & Francis; 1994.
Schmidt U, Treasure J. Clinician's guide to getting better bit(E) by bit(E): a
survival kit for sufferers of bulimia nervosa and binge eating disorders. Sussex,
UK: Taylor & Francis, Psychology Press; 1997.
Siegel M, Brisman J, Weinshel M. Surviving an eating disorder: strategies for
families and friends. New York, NY: Harper Collins Publishers; 1988.

2. Websites for Physicians

Academy for Eating Disorders; 2013 [cited 2013 Feb 15]. Available from:
http://www.aedweb.org//AM/Template.cfm?Section=Home
Eating Disorders of York Region; 2013 [cited 2013 Feb 15]. Available from:
http://www.edoyr.com/
3. Websites for Patients and Families
Bulimia help; 2008 [cited 2013 Feb 15]. Available from:
http://www.bulimiahelp.org/
Eating disorder recovery; 2012 [cited 2013 Feb 15]. Available from:
http://eatingdisorderrecovery.com/
National Eating Disorders Association; 2013 [cited 2013 Feb 15]. Available
from: http://www.nationaleatingdisorders.org/
Sheena’s Place; 2013 [cited 2013 Feb 15]. Available from:
http://www.sheenasplace.org/

4. Videos for Patients and Families

Wicholas B. Parents and eating disorders treatment. Kelty Mental Health; 2011
Jun 20 [cited 2013 Feb 15]. Available from:
http://www.youtube.com/watch?v=axSo3aQdfvo
Wicholas B. Understanding eating disorders for families; 2011 Jun 20 [cited
2013 Feb 15]. Available from:
http://www.youtube.com/watch?v=KellmifQFQ4

17 Bulimia and Nervosa: Purging Patients’ and Families’ Misconceptions