The document discusses Anorexia Nervosa and Bulimia Nervosa. It provides diagnostic criteria for each disorder according to the DSM-5 including prevalence, features, development and course, cultural considerations, measurements, specifiers, severity levels, differential diagnoses, and treatments. Anorexia is characterized by restricted food intake and fear of weight gain while bulimia involves binge eating and compensatory behaviors to prevent weight gain such as vomiting. Both disorders are more common in females and typically begin in adolescence/young adulthood. Treatments involve psychotherapy, medication, and addressing medical complications.

1. Eating Disorders: Anorexia Nervosa,
Bulimia Nervosa
University of Massachusetts, Amherst
Nursing 690M
Donna Petko, MSN, RN, APN, FNP-BC
April 17, 2015

2. Objective
• prevalence
• diagnostic criteria
• development
• functional
consequences
• cultural issues
• measurements
• diagnostic features
• specifiers
• severity levels
• differential diagnoses
• ICD-10 coding
To increase understanding of Anorexia Nervosa
& Bulimia Nervosa in the DSM-5 (APA, 2013):

3. Eating Disorders: Anorexia Nervosa &
Bulimia Nervosa

4. Anorexia
Prevalence (APA, 2013):
• 12 month prevalence among young females 0.4%
• Less common in males
• 10:1 female-to-male ratio

5. Anorexia Cont.
Diagnostic Criteria & Features (APA, 2013):
• Criterion A
▫ Maintains body weight that is below minimally normal level
for age, sex, developmental trajectory, and physical health
• Criterion B
▫ Display intense fear of gaining weight or becoming fat
• Criterion C
▫ Experience and significance of body weight and shape are
distorted

6. Anorexia Cont.
Diagnostic Criteria & Features Cont. (APA, 2013):
• 3 Features:
▫ Persistent energy intake restriction
▫ Intense fear of gaining weight or becoming fat or persistent
behavior that interferes w/ weight gain
▫ Disturbance in self-perceived weight or shape

7. Anorexia Cont.
Development & Course (APA, 2013):
• Typically begins in adolescence/young adulthood
• Rarely begins before puberty or after age 40
▫ Early and late onset are possible
• Onset often associated with a stressful life event
• Course/outcome are highly variable

8. Anorexia Cont.
Functional Consequences (APA, 2013):
• May exhibit a range of functional limitations
▫ Some individuals may remain active in social/professional
functioning
▫ Others may demonstrate significant social isolation and/or
failure to fulfill academic or career potential

9. Anorexia Cont.
Cultural Considerations (APA, 2013):
• Occurs across culturally and socially diverse populations
• Cross-cultural variation in occurrence and presentation
• Prevalent in post-industrialized, high income countries:
▫ US, Europe, Australia, New Zealand, Japan
• Low among Latinos, African Americans, and Asians

10. Anorexia Cont.
Measurements (APA, 2013):
• The SCOFF questionnaire:
▫ Screens for eating disorders using 5 simple, easy-to-
remember questions
▫ An eating disorder can be suspected with 84.6% sensitivity
and 89.6% specificity if a patient responds positively to 2 or
more questions.
▫ The negative predictive value is 99.3% for the SCOFF
questionnaire

11. Anorexia Cont.
Measurements Cont.(APA, 2013):
• The SCOFF questions:
▫ Do you make yourself Sick because you feel uncomfortably
full?
▫ Do you worry that you have lost Control over how much
you eat?
▫ Have you recently lost more than One stone (14 lb) in a 3-
month period?
▫ Do you believe yourself to be Fat when others say you are
too thin?
▫ Would you say that Food dominates your life?

12. Anorexia Cont.
Specifiers (APA, 2013):
• Specify whether:
▫ (F50.01) Restricting type:
 During last 3 months, individual did not engage in binge
eating/purging
▫ (F50.02) Binge-eating/purging type:
 During last 3 months, individual has engaged in binging
eating/purging

13. Anorexia Cont.
Specifiers Cont.
• Specify if:
▫ In partial remission: After full criteria for AN were
previously met, Criterion A (low body wt) has not been met,
but B (fear of gaining wt) & C (disturbance in perception of
wt/shape) is still met
▫ In full remission: After full criteria for AN were
previously met, none of the criteria have been met for a
sustained time

14. Anorexia Cont.
Specifiers Cont. (APA, 2013):
• Specify Current Severity:
▫ Mild: BMI ≥ 17 kg/m²
▫ Moderate: BMI 16-16.99 kg/m²
▫ Severe: BMI 15-15.99 kg/m²
▫ Extreme: BMI < 15 kg/m²
ICD 10 Coding & Severity (APA, 2013):
•307.1

15. Anorexia Cont.
Differential Diagnosis (APA, 2013):
• Medical conditions (e.g., GI disease, hyperthyroid, occult
malignancies, AIDS)
• Major depressive disorder
• Schizophrenia
• Substance use disorders
• Social anxiety disorder, obsessive-compulsive disorder,
body dysmoric disorder
•Bulimia Nervosa
•Avoidant/restrictive food intake disorder

16. Anorexia Cont.
Initial Tests (Epocrates, 2015):
• CBC
• Serum chemistry
• TFTs
• LFTs
• Urinalysis
• Urine pregnancy test
• ECG

17. Anorexia Cont.
Treatment (Epocrates, 2015):
• Structured eating plan with oral nutrition
• Psychotherapy
• In-patient admission:
▫ Oral, enteral, parental nutrition
▫ Fluid intake correction
▫ Potassium repletion
▫ Magnesium repletion
▫ Calcium repletion
▫ Sodium repletion
• SSRIs

18. Bulimia
Prevalence (APA, 2013):
• 12 month prevalence among young females is 1-1.5%
• Highest among young adults
▫ Peaks in adolescence
• Less common in makes
• 10:1 female-to-male ratio

19. Bulimia Cont.
Diagnostic Criteria & Features (APA, 2013):
• Criterion A
▫Recurrent episodes of binge eating:
 Eating, in a discrete period of time, an amount of food that is
larger than most individual would consume in a similar period of
time
 Sense of lack of control over eating during the episode
• Criterion B
▫Recurrent inappropriate compensatory behaviors in order to
prevent weight gain:
 Vomiting, laxative use, diuretics, other meds, fasting, excessive
exercise

20. Bulimia Cont.
Diagnostic Criteria & Features (APA, 2013):
• Criterion C
▫ Binge eating and inappropriate compensatory behaviors
occur, on average, at least once a week for 3 months
• Criterion D
▫ Self-evaluation is unduly influenced by body shape/weight
• Criterion E
▫ The disturbance does not occur exclusive during episodes of
AN

21. Bulimia Cont.
Diagnostic Criteria & Features Cont. (APA, 2013):
• 3 Features:
▫ Recurrent episodes of binge eating
▫ Recurrent inappropriate compensatory behaviors to
prevent weight gain
▫ Self-evaluation that is unduly influenced by body
shape/weight
• To qualify for diagnosis, behavior must occur, on
average, at least once a week for 3 months

22. Bulimia Cont.
Development & Course (APA, 2013):
• Commonly begins in adolescence or young adulthood
• Onset before puberty or after age 40 uncommon
• Frequently begins during or after a dieting episode
• Experiencing multiple stressful life events can precipitate
onset
• Behavior may persist for several years
• Elevated risk for mortality
• Diagnostic cross-over from BM to AN occurs in minority
of cases (10-15%)

23. Bulimia Cont.
Functional Consequences (APA, 2013):
• May exhibit a range of functional limitations
• Some report severe role impairment
▫Social-life domain likely to be affected

24. Bulimia Cont.
Cultural Considerations (APA, 2013):
• Similar frequencies in most industrialized countries
▫ US, Canada, Europe, Australia, Japan, New Zealand, South
Africa
▫ Individuals presenting in US predominately white
• Occurs in other ethnic groups with prevalence
comparable to estimated prevalence in white samples

25. Bulimia Cont.
Measurements Cont.(APA, 2013):
• The SCOFF questionnaire:
▫ Screens for eating disorders using 5 simple, easy-to-
remember questions.
▫ An eating disorder can be suspected with 84.6% sensitivity
and 89.6% specificity if a patient responds positively to 2 or
more questions.
▫ The negative predictive value is 99.3% for the SCOFF
questionnaire

26. Bulimia Cont.
Measurements Cont.(APA, 2013):
• The SCOFF questions:
▫ Do you make yourself Sick because you feel uncomfortably
full?
▫ Do you worry that you have lost Control over how much
you eat?
▫ Have you recently lost more than One stone (14 lb) in a 3-
month period?
▫ Do you believe yourself to be Fat when others say you are
too thin?
▫ Would you say that Food dominates your life?

27. Bulimia Cont.
Specifiers (APA, 2013):
• Specify if:
▫ In partial remission: After full criteria for BN were
previously met, some, but not all, criteria have been met for
a sustained time
▫ In full remission: After full criteria for BN were
previously met, none of the criteria have been met for a
sustained time

28. Bulimia Cont.
Specifiers (APA, 2013):
• Specify current severity:
▫ Mild: Average of 1-3 episodes of inappropriate
compensatory behaviors per week
▫ Moderate: 4-7 episodes
▫ Severe: 8-13 episodes
▫ Extreme: 14 or more episodes

29. Bulimia Cont.
ICD-10 Coding & Severity (APA, 2013):
• 307.51 (F50.2)

30. Bulimia Cont.
Differential Diagnosis (APA, 2013):
• Anorexia
▫binge-eating/purging type
• Binge-eating disorder
• Kleine-Levin syndrome
• Major depressive disorder
▫w/ atypical features
• Borderline personality disorder

31. Bulimia Cont.
Initial Tests (Epocrates, 2015):
• CBC
• Serum electrolytes
• Serum creatinine
• Serum magnesium
• Urine pregnancy test
• Serum LFTs
• Serum CK
• Urinalysis
• ECG

32. Bulimia Cont.
Treatment (Epocrates, 2015):
• Cognitive Behavioral Therapy
• Nutritional/meal support
• SSRIs, SNRIs
• Other types of psychological therapies
• Referral for specialist evaluation or emergency
department assistance
• Glycemic control

34. Case Study
A 21-year-old woman is brought into an outpatient clinic by her mother, who
complains that her daughter has been demonstrating unusual eating patterns since
she moved back home 6 months ago. Her mother observes her to eat large amounts
of food, such as desserts, when she is alone, often finding food wrappers hidden in
her daughter’s room. She is worried that her daughter may be engaging in vomiting
after these episodes of heavy eating. She often isolates herself in the bathroom for 10-
20 minutes after a large meal.
When the patient was asked about her eating habits, she admitted to a “loss of
control.” She described feeling deep remorse when she eats more than she would like.
Furthermore, she described feeling so laden with guilt about her eating binges that
she purposefully induces vomiting at least once every other day. This act gives her
tremendous relief. She admits that she is unhappy with her overall appearance, and
feels that she is “fat” and “out of shape.” She is preoccupied with her appearance and
says that she compares herself to other women “all day long.” She also admits to
feeling sad most days. She endorses experiencing occasional missed menstrual
periods, low libido, low energy, and intermittent sore throat.
(Yager & Bienenfield, 2013, para. 1)

35. Case Study Cont.
Historically, the patient has memories of a chaotic childhood. She is an only child
whose parents fought often and finally divorced when she was 9 years old. The
patient remembers the first time she induced vomiting at 10 years old, after she felt
“too full after a large meal.” The mother describes her daughter as having few friends
and as tending to isolate herself. However, the mother describes her as very bright; in
fact, she was valedictorian of her high school.
On physical examination, the patient’s blood pressure is 90/60, heart rate is 100, and
BMI is 19. Her oropharynx appears injected without areas of erosion, and multiple
dental caries are seen. Bilateral parotid enlargement with minor tenderness is
present. The patient is tachycardic and bowel sounds are hyperactive. The abdomen
is soft, nontender, and nondistended. Skin turgor is poor.
(Yager & Bienenfield, 2013, para. 1)

36. Case Study Cont.
On mental status examination, the patient presents as a young Caucasian woman
with average body habitus and pale skin. She is meticulously dressed and groomed.
She answers questions curtly, makes poor eye contact, and demonstrates mild foot
tapping throughout the interview. Her mood is anxious and her affect is mood
congruent but restricted to negative emotionality. She is highly articulate. Thought
process is linear and goal directed. Methodical about her statements, she often takes
time to clarify what she “really means.”
Thought content displays themes of shame, guilt, and self-reproach. No active
delusions or hallucinations are present. Her cognition is grossly intact. She denies
suicidal thoughts, but sometimes wishes she was “invisible.” She has no violent or
homicidal thoughts. Insight is limited regarding her ability to acknowledge her
psychiatric illness. Her judgment is impaired considering her inability to recognize
the potential negative health consequences of her eating behaviors.
(Yager & Bienenfield, 2013, para. 1)

37. Case Study Cont.
Prior to entering your office, laboratory assessment obtained at the suggestion
of her primary care doctor reveals a serum potassium level of 3.8 Meq/L and
serum amylase level of 140 Units/L.
▫ Take home points:
 The differential diagnosis of bulimia nervosa includes depression, anxiety and
age-appropriate developmental problems (e.g., lack of esteem). These issues
are common co-occurrences.
 A biopsychosocial treatment plan will be necessary to provide her the care she
needs.
 Collaboration with primary care providers is often necessary for short-term
and sometimes long-term.
(Yager & Bienenfield, 2013, para. 1)

38. References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington
D.C.: Author.
Yager, J. & Bienenfield, D. (2014). Bulimia Nervosa clinical
presentation. Retrieved from http://emedicine.
medscape.com/article/286485-clinical
Epocrates. (2015). Anorexia Nervosa. Retrieved from
https://online.epocrates.com/u/2942440/Anorexia
+nervosa/Treatment/Tx+Details
Epocrates. (2015). Bulimia Nervosa. Retrieved from
https://online.epocrates.com/noFrame/showPage?meth
od=diseases&MonographId=441&ActiveSectionId=42
Rushing, J.M., Jones, L.E., Carney, C.P. (2003). Bulimia
Nervosa: A primary care review. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419300/