Our initial task is to define bulimia nervosa. However, before we can meaningfully discuss criteria for this disorder, we need to first decide on a frame of reference. What type of model best describes this disorder? Should bulimia nervosa be regarded as a disease? This construct, which presupposes some underlying pathophysiology and a predictable course, is the model used in the current view of schizophrenia and primary affective disorder and in most of medicine. Unfortunately this model does not fit well with much of what is known about bulimia nervosa. No one has yet been able to delineate a specific...

Let us address the core behavioral symptoms of bulimia nervosa, beginning with the hallmark of the disorder-binge-eating. The binge-eating behavior usually starts during a period of restrictive dieting, when the individual loses control and overeats.^160,356,463The onset can also be associated with stressful life events.⁵⁶

We have previously mentioned the lack of a precise definition for binge-eating, and that this imprecision results in a major stumbling block to research. It would be convenient if binge-eating clearly differed from “normal” eating or “overeating” (another currently undefinable construct), but on the spectrum of eating, binge-eating must merge with overeating. To make matters...

Bulimia nervosa is frequently accompanied by other forms of psychopathology and other associated difficulties. We turn now to a discussion of these areas.

There is much evidence to suggest a strong link between these disorders.^171,432,458Much of this work has been published by Pope, Hudson, and their colleagues at Maclean Hospital, who have been particularly interested in this association. The relationship with depression is important to our understanding of bulimia nervosa and quite controversial,^{72,189,265,303,447,462,474}(as reiationship between anorexia nervosa and depression)^50,89and we will discuss it in some depth.

First, there is an apparently high rate of depression...

This chapter is devoted to a discussion of diagnostic interview techniques that can be used to identify individuals with bulimia nervosa. Some of this material has been included, in a different form, in a published patient selfreport database, the Eating Disorders Questionnaire, developed at the University of Minnesota.₃₀₁

The information presented here should be included in a thorough evaluation history of an individual with an eating disorder. Although the suggested interview format is suitable for patients with other eating problems, it is designed specifically for bulimic individuals.

Before turning to the specifics of the interview, I will make some...

Bulimia nervosa is a more medically benign condition than anorexia nervosa, wherein most of the medical complications are attributed to starvation.²³⁹However, some physicians and therapists who work with eating disorders patients assume that this condition is not physically hazardous, underestimating the potential for complications. In this chapter, we will review the major medical complications of this disorder and offer guidelines for their assessment and management. For those interested, there are several additonal books and papers that offer much useful summary information on these complications.^{39,82,59,134,292,318,431,477}The most important point of the chapter is that all patients with bulimia nervosa should...

Over the last few decades knowledge in the field of neurobiology, has dramatically increased, and it is safe to say that advances in this area are among the most important and innovative in all of science. A part of this increase in knowledge has been a marked expansion of our understanding of the biological mechanisms that regulate weight, appetite, and feeding. Although much of this research has yet to be translated into human applications, attempts are now being made to bridge the basic science and the clinical—to use basic science findings to generate theories about the causes of eating...

Many mental health professionals who work with bulimia patients have a very limited background in nutritional science. Also of interest, the dieticians who work with these patients generally have a rather limited training in counseling techniques. Both of these limitations are unfortunate, in that both psychotherapy and nutritional counseling are important in the treatment of this disorder. Integration of these treatment aspects can be accomplished in several ways. Many programs use a team approach, wherein a dietician is responsible for the nutritional counseling elements and someone else is responsible for the psychotherapy and/or pharmacotherapy components. However, such an arrangement is...

One of the true success stories in clinical neurosciences over the last 30 or so years has been the development of effective drug therapies of several psychiatric disorders. This era was heralded by the introduction of chlorpromazine for the treatment of schizophrenia in the early 1950s. Since that time, drug therapy has come to play an important part in the treatment of many emotional and behavioral disorders, several of which were previously difficult or impossible to treat. These include schizophrenia, affective disorders, obsessive compulsive disorder, and other anxiety disorders. Therefore, it is logical and important to attempt to find medications...

There are many reasons to be optimistic about the treatment of patients with bulimia nervosa. Published treatment studies show quite clearly that most individuals with this disorder improve dramatically with therapy and that many apparently recover from the condition. However, there are important questions concerning treatment that we cannot yet answer, including the relative efficacy of various treatments and which treatments are best for which patients. We know even less about the possibility of longterm relapse following treatment, and the relative prophylactic effects of various interventions.

In this chapter we will review the published psychotherapy treatment studies of bulimia nervosa....

In this chapter I will comment on strategies that can be used in the treatment of patients with bulimia nervosa, and offer several specific techniques. In general, these techniques can be used in both individual and group therapy, and in both inpatient and outpatient settings.

The primary strategy I will outline is highly structured, and utilizes psychoeducational, behavioral, and cognitive-behavioral techniques, as well as the nutritional counseling techniques discussed previously. The major goal of this strategy is to provide patients with the skills and knowledge they need to gain control of their bulimic behaviors and to replace them with healthier,...

I hope that those who read this book, or sample portions of it, find this disorder as interesting and challenging as I do. I believe there are few examples in medicine or psychology of a disorder that can have such globally adverse effects on an individual’s life, yet which is clearly treatable and reversible. The other thing that I find particularly interesting about bulimia nervosa is that a number of variables must be involved in its etiology. There is growing evidence that biological, perhaps genetic, factors contribute to the risk of development of and maintenance of this disorder; second, cultural...