DSM-III

In DSM-III, this disorder is called Bulimia

Diagnostic Criteria

A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time, usually less than two hours).

B. At least three of the following:

  1. consumption of high-caloric, easily ingested food during a binge
  2. inconspicuous eating during a binge
  3. termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting
  4. repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diuretics
  5. frequent weight fluctuations greater than ten pounds due to alternating binges and fasts

C. Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.

D. Depressed mood and self-deprecating thoughts following eating binges.

E. The bulimic episodes are not due to Anorexia Nervosa or any known physical disorder.

Differential Diagnosis

Anorexia Nervosa

In Anorexia Nervosa there is severe weight loss, but in Bulimia the weight fluctuations are never so extreme as to be life-threatening.

Schizophrenia

In Schizophrenia there may be unusual eating behavior, but the full syndrome of Bulimia is rarely present; when it is, both diagnoses should be given.

Neurological diseases

In certain neurological diseases, such as epileptic equivalent seizures, CNS tumors, Klüver-Bucy-like syndromes, and Klein-Levin syndrome, there are abnormal eating patterns, but the diagnosis Bulimia is rarely warranted; when it is, both diagnoses should be given.

DSM-IV

Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
  2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type:

  • Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
  • Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or misuse of laxatives, diuretics, or enemas

Subtypes

The following subtypes can be used to specify the presence or absence of regular use of purging methods as a means to compensate for the binge eating:

Purging Type

This subtype describes presentations in which the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode.

Nonpurging Type

This subtype describes presentations in which the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episodes.

Differential Diagnosis

Anorexia Nervosa

Individuals whose binge-eating behavior occurs only during Anorexia Nervosa are given the diagnosis Anorexia Nervosa, Binge-Eating/Purging Type, and should not be given the additional diagnosis of Bulimia Nervosa. For an individual who binges and purges but whose presentation no longer meets the full criteria for Anorexia Nervosa, Binge-Eating/Purging Type (e.g., when weight is normal or menses have become regular), it is a matter of clinical judgment whether the most appropriate current diagnosis is Anorexia Nervosa, Binge-Eating/Purging Type, In Partial Remission, or Bulimia Nervosa.

General Medical Conditions and other mental disorders

In certain neurological or other general medical conditions, such as Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psychological features of Bulimia Nervosa, such as overconcern with body shape and weight, are not present. Overeating is common in Major Depressive Disorder, With Atypical Features, but such individuals do not engage in inappropriate compensatory behavior and do not exhibit the characteristic overconcern with body shape and weight. If criteria for both disorders are met, both diagnoses should be given. Binge-eating behavior is included in the impulsive behavior criterion that is part of the definition of Borderline Personality Disorder. If the full criteria for both disorders are met, both diagnoses can be given.

DSM-5

Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
  2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if:

  • In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.
  • In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

  • Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.
  • Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
  • Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.
  • Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Differential Diagnosis

Anorexia nervosa, binge-eating/purging type

Individuals whose binge-eating behavior occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, binge-eating/purging type, and should not be given the additional diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa who binge and purge but whose presentation no longer meets the full criteria for anorexia nervosa, binge-eating/purging type (e.g., when weight is normal), a diagnosis of bulimia nervosa should be given only when all criteria for bulimia nervosa have been met for at least 3 months.

Binge-eating disorder

Some individuals binge eat but do not engage in regular inappropriate compensatory behaviors. In these cases, the diagnosis of binge-eating disorder should be considered.

Kleine-Levin syndrome

In certain neurological or other medical conditions, such as Kleine-Levin syndrome, there is a disturbed eating behavior, but the characteristic psychological features of bulimia nervosa, such as overconcern with body shape and weight, are not present.

Major depressive disorder, with atypical features

Overeating is common in major depressive disorder, with atypical features, but individuals with this disorder do not engage in inappropriate compensatory behaviors and do not exhibit the excessive concern with body shape and weight characteristic of bulimia nervosa. If criteria for both disorders are met, both diagnoses should be given.

Borderline personality disorder

Binge-eating behavior is included in the impulsive behavior criterion that is part of the definition of borderline personality disorder. If the criteria for both borderline personality disorder and bulimia nervosa are met, both diagnoses should be given.

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