Bulimia in Children and Adolescents

BN is characterized by three main symptoms:

• Recurrent episodes of binge eating, in which the person eats a very large amount of food in a discrete period of time (e.g., a two-hour period).  During these eating binges the person experiences a sense of loss of control, or a sense that he/she is unable to stop eating or control what or how much he/she is eating.
• Recurrent inappropriate compensatory behaviors, in which the person attempts to prevent weight gain.  Common compensatory behaviors include self-induced vomiting, misusing laxatives or other medications, fasting, or exercising excessively.
• Overemphasis on body weight and shape, including a very strong influence of weight and shape on the individual's self-esteem.

For a child or adolescent to be diagnosed with BN, eating binges and accompanying purging behaviors must occur, on average, at least once per week for three months or longer.  If these behaviors are associated with significantly low body weight and occur within the context of anorexia nervosa, anorexia nervosa (binge-eating/purging type) would be diagnosed instead of BN.

Several factors can be useful to distinguish a binge from normal overeating.  The definition of "a very large amount of food" is subjective, but is usually defined as an amount that is significantly greater than most individuals would eat in a similar situation.  Often the individual will feel uncomfortably or painfully full after a binge.  Individuals with BN often describe a sense of dissociation or complete inability to control their food consumption once a binge has started, and they may eat foods they might otherwise avoid.  These binges often lead the individual to feel ashamed; consequently, many individuals with BN will binge and purge in secret.  These individuals may not be forthcoming about their binging or purging behaviors due to guilt, shame, or fear of stigma.

BN severity can range from mild to very severe.  In severe cases, BN can lead to serious medical complications, including fluid and electrolyte disturbances, esophageal tears, and disturbances in the cardiac and gastric systems.  More generally, children and adolescents with BN may have significant difficulty attending or concentrating at school and may have strained family and peer relationships.  Children and adolescents with BN also have other psychiatric conditions, most commonly depressive disorders, bipolar disorder, anxiety disorders, substance use disorders, and personality disorders.

BN is characterized by abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to dysregulation in the serotonergic and striatal dopaminergic systems in the brain.  Neurobiological models of BN suggest that regularly binging on palatable food may alter the dopamine, acetylcholine, and opioid systems in reward-related brain areas, leading to the maintenance of symptoms.  In addition, overconcern about weight and shape is thought to lead to the adoption of purging behaviors, which results in a vicious cycle of binging, purging, and restricting.  The disorder is thought to have a genetic component, although having a predisposition to BN does not necessarily mean that someone will develop BN.  

Treatment of BN should typically include a multidisciplinary team that includes a pediatrician, psychologist, and dietician.  In the absence of an acute medical need, outpatient therapy is generally preferable to inpatient hospitalization as a first-line treatment for children and adolescents with BN.

Clinical research and expert guidelines suggest that the following treatments are effective for children and adolescents with BN:

• Family-based therapy (FBT), sometimes known as the Maudsley method, is the treatment of choice for children and adolescents with bulimia nervosa.  FBT is a longer-term (6 - 12 month) outpatient-based family therapy in which parents take control of the child's eating and weight restoration.
• Cognitive-behavioral therapy for eating disorders (CBT-E), in which distorted thoughts and behavioral patterns are identified and modified, has also shown promising results for treating bulimia nervosa in adolescents.

In addition, research suggests that the following treatments are promising:

The antidepressant medication fluoxetine improves symptoms by altering the amount of serotonin in the brain.  Antidepressant medications should not be used as a monotherapy for BN but may have some benefit as a second-line treatment for adolescents with BN.