Bulimia nervosa and binge eating disorder

Context for development of the guidelines

This theme was the subject of a joint request to the French National Authority for Health (HAS) to include it in its programme by the Directorate General of Health Care Provision (DGOS) and the French National federation of eating disorder support associations (FNA-TCA).

The French Federation of anorexia and bulimia (FFAB) (formerly the French Association for the development of specialised approaches for the treatment of eating disorders [AFDAS-TCA]), which had produced the guidelines on anorexia nervosa in partnership with the HAS in 2010, was also involved in this request, along with the following bodies:

• the French Psychiatry Congress;
• the French National Council for Healthcare Professionals – National college for the quality of psychiatric care (CNPP-CNQSP);
• the French-speaking association for clinical nutrition and metabolism (SFNCM);
• INSERM unit U669 (PSIGIAM: Paris-Sud innovation group in adolescent mental health) led by Prof. Bruno Falissard.

These best practice guidelines were developed under the responsibility of the French Federation of anorexia and bulimia (FFAB) and the HAS, working closely with the other disciplines concerned.

Objectives of the best practice guidelines

The aim of these best practice guidelines (BPG) is to supplement the BPG on “Anorexia nervosa, management” published in 2010, developed by the HAS in partnership with the AFDAS-TCA. The objective is to offer professionals BPGs relative to all eating disorders (EDs) in order to define strategies for improving the organisation of their diagnosis and care.

In particular, these guidelines cover the following aspects:

• early detection and management: risk factors, warning signs, first consultations for bulimia or binge eating disorder in adolescents and adults: what assessment, what referrals, role of the parents and environment, particularly school; role of family and friends;
• the long-term follow-up of an adult or adolescent (psychiatric and somatic components);
• the management of patients with eating disorders arriving in an emergency department (medical or psychiatric emergencies).

Drafting method

The Clinical practice guidelines method was used. This method is described in the appendices and, in detail, in the HAS methodological guide[1] available on its website.

The majority of the recommendations are based on expert consensus within the expert group. The absence of grading does not mean that the recommendations are not relevant and useful. However, it should prompt additional studies. They should apply to the majority of cases, sometimes with adjustment on a case-by-case basis.

Patients concerned

Adolescents and adults, along with their families and/or the people around them

Professionals concerned

General practitioners, paediatricians, child and adult psychiatrists, dieticians, dentists and orthodontists, gynaecologists, school doctors and nurses (and the school environment in general), psychologists, endocrinologists, nutritionists, emergency physicians, intensive care specialists, sports medicine specialists, company doctors, gastroenterologists, midwives, physiotherapists.

Definitions and scope of recommendations

These guidelines concern bulimia nervosa and binge eating disorder, and partial forms of bulimia nervosa and binge eating disorder.

• Bulimia nervosa is characterized by episodes of binge eating (consumption of a large amount of food in a short period of time, accompanied by a feeling of being out of control) followed by inappropriate compensatory behaviours, such as: self-induced vomiting, misuse of laxatives, diuretics or other medicines; fasting; excessive exercise. In addition, self-esteem is unduly influenced by physical appearance in these individuals. Bulimia sufferers usually have a normal body mass index (BMI) due to their compensatory behaviours.
• Binge eating disorder is characterised by recurrent episodes of binge eating, but without the inappropriate compensatory behaviour seen in bulimia nervosa. For this reason, binge eating disorder generally leads to high BMI (overweight or obesity). Binge eating causes significant distress.

The exact characterisation of DSM-5 has been very little used in the research published to date (most of the research predates DSM-5 and uses DSM-IV or DSM-IV-R criteria). We therefore opted to retain the denomination of eating disorders and binge eating disorder. For the eating disorders not otherwise specified with binge eating behaviours of the DSM-IV-TR (EDNOS: lower frequency of episodes or absence of certain criteria) and the “other specified feeding or eating disorders” of the DSM-5 (“bulimia nervosa of low frequency and/or limited duration”, “binge eating disorder of low frequency and/or limited duration”, and “purging disorder”), we have used the generic term “partial forms of bulimia nervosa and binge eating disorder”.

Anorexia nervosa with episodes of bulimia/vomiting or purging will not therefore be considered in these guidelines since it was already covered in the HAS/AFDAS-TCA guidelines on “Anorexia nervosa, management", published in 2010.

Rare diseases leading to binge eating behaviours with loss of satiety (e.g.: Prader-Willi syndrome, Bardet Biedl syndrome, Alström syndrome, etc.) are excluded from the scope of these guidelines.

[1] https://www.has-sante.fr/portail/jcms/c_431294/recommandations-pour-la-pratique-clinique-rpc