General Information (including ICD-9/-10 Codes)

Description :

  • eating disorder, repetitive binge eating associated with purging by vomiting (with or without use of laxatives or diuretics)

Also called :

  • bulimia nervosa

ICD-9 Codes :

  • 307.51 bulimia

ICD-10 Codes :

  • F50.2 bulimia nervosa
  • F50.3 atypical bulimia nervosa
  • F50.4 overeating associated with other psychological disturbances
  • F50.5 vomiting associated with other psychological disturbances
  • F50.8 other eating disorders
  • F50.9 eating disorders, unspecified

Who is most affected :

  • primarily young women and older teenagers, average age 17-18, white middle and upper class
  • phone interviews of 1,628 black women and 5,741 white women 18-40 (mean age 29.7) found that black women were as likely as white women to report binge eating or vomiting in previous 3 months and more likely to report fasting and abuse of laxatives or diuretics (Arch Fam Med 2000 Jan;9(1):83 full-text); accompanying editorial points out that studies underlying claim that eating disorders are more common in white middle and upper class have significant limitations (Arch Fam Med 2000 Jan;9(1):88)

Incidence/Prevalence :

  • relatively common, may be as high as 5%
  • in study of Australian school children (888 girls and 811 boys) 14-15 years old at beginning of study and followed 3 years
  • < 1% prevalence reported in pregnant women in Norway
    • based on questionnaire study of 41,157 pregnant women in Norway
    • prepregnancy prevalence estimates were 0.1% for anorexia nervosa, 0.7% for bulimia nervosa, 3.5% for binge eating disorder and 0.1% for recurrent self-induced purging in absence of binge eating
    • early pregnancy prevalence estimates were 0.2% for bulimia nervosa, 4.8% for binge eating disorder and 0.1% for recurrent self-induced purging in absence of binge eating
    • Reference - Psychol Med 2007 Aug;37(8):1109

Causes and Risk Factors

Causes :

  • disturbed self-image, depression

Pathogenesis :

  • desire to lose weight
  • difficulty in sensing the self
  • fear of not being able to stop eating

Likely risk factors :

  • family history of depression, suicide, substance abuse; history of sexual abuse
  • in study of Australian school children (888 girls and 811 boys) 14-15 years old at beginning of study and followed 3 years, risk factors for development of eating disorders were dieting and psychiatric morbidity (BMJ 1999 Mar 20;318(7186):765), commentary can be found in BMJ 1999 Jun 26;318(7200):1761
  • diabetes mellitus type 1 associated with increased risk for eating disorders
    • based on comparison of 356 Canadian females aged 12-19 years with type 1 diabetes vs. 1,098 age-matched non-diabetic controls
    • comparing girls with diabetes vs. controls
      • 10% vs. 4% had eating disorders that met DSM-IV criteria (p < 0.001)
      • 14% vs. 8% had subthreshold eating disorders (p < 0.001)
    • Reference - BMJ 2000 Jun 10;320(7249):1563 full-text

Possible risk factors :

  • perfectionism and negative self-evaluation are common precedents to anorexia nervosa
  • beginning to purge to lose weight associated with importance of thinness to peers and trying to look like females on TV, in movies or in magazines
    • based on 1-year prospective study of 7,000 girls 9-14 of whom 74 reported use of vomiting or laxatives at least monthly to control weight
    • Reference - Arch Pediatr Adolesc Med 1999 Nov;153(11):1184 in Pediatric Notes 1999 Dec 2;23(48):191

  • eating alone may be a risk factor for developing eating disorders
    • based on study of 2,862 girls aged 12-21 years
    • patients were evaluated twice 18 months apart with 90 (3%) developing eating disorders during follow-up
    • risk factors for incident eating disorder were
      • younger age
      • usually eating alone
      • frequently reading girls' magazines and listening to radio programs
      • parents not being married
    • Reference - Pediatrics 2003 Feb;111(2):315 full-text, commentary can be found in Evid Based Nurs 2003 Oct;6(4):120
  • < 5 family meals weekly associated with increased risk of disordered eating in girls and unhealthy weight control behaviors in boys
    • based on observational study
    • 2,516 adolescents surveyed regarding family meal frequency and surveyed for disordered eating behaviors 5 years later
    • comparing girls having < 5 meals vs. ≥ 5 meals weekly with family
      • extreme weight control behaviors (self-induced vomiting and use of laxatives, diet pills, or diuretics) in 26% vs. 17% (p < 0.001)
      • unhealthy weight control behaviors (eating very little, fasting, using food substitutes, skipping meals, or smoking) in 64.4% vs. 57.4% (p = 0.008)
      • binge eating in 12.7% vs. 9.2% (p = 0.046)
      • chronic dieting in 18.5% vs. 13.9% (p = 0.02)
    • in boys
      • unhealthy weight control behaviors in 29% boys having < 5 family meals weekly vs. 35.4% boys having ≥ 5 family meals weekly (p = 0.02)
      • no significant differences with number of family meals on extreme weight control behaviors, binge eating and chronic dieting
    • Reference - Arch Pediatr Adolesc Med 2008 Jan;162(1):17

  • childhood sexual abuse may be associated with increased risk of bulimia in females
    • based on population-based cohort study
    • 999 adolescent females asked about childhood sexual abuse before age 16 years and followed for mean 9 years
    • risk of bulimia (but not anorexia) significantly higher in females with ≥ 2 reports of childhood sexual abuse (p ≤ 0.05)
    • Reference - Arch Pediatr Adolesc Med 2008 Mar;162(3):261

Complications and Associated Conditions

Complications :

  • complications may be what suggests the diagnosis
  • metabolic disturbances - hypokalemia, alkalosis, hypochloremia, hyponatremia, elevated urine pH
  • arrhythmia, sudden death
  • esophageal or gastric rupture, esophagitis, gastric dilatation
  • sinusitis, parotid and submandibular gland hypertrophy, dental enamel erosion, loss of teeth, aspiration
  • headaches, irregular menses
  • with laxative abuse - chronic constipation and distention, malabsorption, rectal bleeding
  • during pregnancy, women with eating disorders more likely to have anemia and hyperemesis and deliver infants with lower mean birth weight and smaller head circumference; 49 pregnant women with history of eating disorder compared with 68 controls, 8 vs. 0 had infant with microcephaly, 12 vs. 1 had small for gestational age infant (Obstet Gynecol 2005 Feb;105(2):255 in J Watch Online 2005 Mar 4)

Associated conditions :

History

Chief Concern (CC) :

  • poor self-image, depression, suicidal ideation, substance abuse, antisocial behavior, self-mutilation, fear of becoming obese, 100% eating binges, 88% self-induced vomiting, 60% laxative abuse

History of Present Illness (HPI) :

  • ask about eating patterns, food intake history, purging behavior, past weight fluctuations, sexual abuse

Medication History :

  • 33% diuretic or laxative abuse

Family History (FH) :

  • depression, suicide, substance abuse

Social History (SH) :

  • level of depression, risk-taking behavior, family dynamics, affective instability, markedly low self-esteem, poor organization, emotional vulnerability, almost all find condition disruptive within 1 year
  • discontentment with body weight and shape strongly related to frequency of reading fashion magazines in survey of preadolescent and adolescent girls, 47% reported wanting to lose weight because of magazine pictures (Pediatrics 1999 Mar;103(3):e36)

Review of Systems (ROS) :

Physical

General Physical :

  • near-normal weight, check vital signs for hypovolemia

Skin :

  • scars on back of hand

HEENT :

  • check dentition

Neck :

  • lymphadenopathy, submandibular hyperplasia

Cardiac :

  • evaluate cardiac function

Abdomen :

  • tenderness, distention

Diagnosis

Making the diagnosis :

  • DSM-IV-TR criteria
    • recurrent episodes of binge eating with both
      • eating in discrete time period amount of food definitely larger than normal
      • sense of lack of control over eating during episode
    • recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives/diuretics/enemas or other meds, fasting or excessive exercise
    • both occur at least twice weekly for 3 months
    • self-evaluation unduly influenced by body shape and weight
    • exclude diagnosis if symptoms only during anorexia nervosa

Rule out :

  • thyroid dysfunction

Testing to consider :

  • blood chemistries, urine pH, TSH
  • overnight dexamethasone suppression test or 24-hour urine free cortisol
  • sex hormone studies (if amenorrheic)

Blood tests :

  • hypokalemia, metabolic alkalosis or hyperchloremic metabolic acidosis, hypercortisolism, hyperphosphatemia

Urine studies :

  • elevated urine pH (> 7.0)

Imaging studies :

Prognosis

Prognosis :

  • worse than anorexia (psychological recovery)
  • lower mortality than anorexia, with less likelihood of permanent osteoporosis
  • significant chance of long-term eating disorder; long-term follow-up (mean 11.5 years) of 173 women with bulimia who met DSM-III criteria and had binge eating with purging at least 3x/week in previous 6 months, average at onset 17 years, mean duration of symptoms prior to clinical presentation 6 yrs; 18% still met DSM criteria for eating disorder not otherwise specified, 11% met criteria for bulimia nervosa, 1% met criteria for and history of substance abuse (Arch Gen Psychiatry 1999 Jan;56(1):63 in J Watch 1999 Feb 15;19(4):36)
  • eating disorders associated with 2.3% 5-year mortality in prospective study; based on 216 patients, 88 with bulimia had no mortality, 74% of bulimic patients had no diagnosable eating disorder at 5 years but treatment did not appear to be effective (Lancet 2001 Apr 21;357(9264):1254), commentary can be found in Lancet 2001 Sep 15;358(9285):926

Treatment

Treatment overview :

  • stabilize medical condition if presenting in emergency
  • follow weight, diet, exercise
  • review available treatment (drug, psychology, psychiatry, family)
  • antidepressants clinically effective, but supporting evidence of poor quality
  • cognitive behavior therapy (CBT) shows some efficacy
  • primary conclusions from systematic review of 47 treatment studies for bulimia nervosa
  • combination antidepressants plus psychological treatments more effective than psychological treatment alone
    • combination probably more effective than antidepressants alone but not statistically significant
    • antidepressants associated with higher dropout rates
    • systematic review of randomized trials comparing antidepressants, psychological approaches or their combination for bulimia nervosa
    • remission defined as 100% reduction in binge or purge episodes from baseline to endpoint
    • antidepressants vs. psychological treatments compared in 5 trials, 20% vs. 39% remission rates (not statistically significant), dropout rates were higher with antidepressants (NNH 4 or mean treatment duration 17.5 weeks)
    • antidepressants vs. combination compared in 5 trials, 23% vs. 42% remission rates (not statistically significant)
    • psychological treatments vs. combination compared in 7 trials, 36% vs. 49% remission rates (NNT 8 for mean treatment duration 15 weeks), dropout rates higher for combination (NNH 7)
    • Reference - systematic review last updated 2001 Aug 13 (Cochrane Library 2001 Issue 4:CD003385), commentary can be found in ACP J Club 2002 May-Jun;136(3):107

Counseling :

  • cognitive behavior therapy (CBT) shows some efficacy
    • small body of evidence for efficacy of cognitive-behavior therapy in bulimia nervosa, but quality of trials is very variable and sample sizes often very small; systematic review of randomized trials of psychotherapy for bulimia or related eating disorders; studies suggest efficacy for CBT (especially CBT developed for bulimia nervosa) and other psychotherapies (especially interpersonal psychotherapy), psychotherapy alone unlikely to change body weight; systematic review last updated 2004 Apr 21 (Cochrane Library 2004 Issue 3:CD000562)
    • cognitive-behavioral therapy + medication was most effective approach in short (16 weeks) study of 120 women 18-45 with bulimia randomized to cognitive-behavioral therapy with drug or placebo, supportive psychotherapy with drug or placebo, or drug (desipramine with change to fluoxetine if necessary) (Am J Psychiatry 1997 Apr;154(4):523 in J Watch 1997 May 15;17(10):79)
    • cognitive behavior therapy (CBT) and medication both effective, CBT most effective single treatment; meta-analysis of 9 placebo-controlled medication trials (870 patients) and 26 psychosocial trials (CBT, behavioral therapy, or exposure and response prevention) (460 patients) in patients with bulimia nervosa by DSM-III criteria; medication and CBT both effective for reducing binge frequency, purge frequency, depression and eating attitudes; effect sizes higher for CBT than for medication alone, combination therapy associated with higher effect sizes for binge and purge frequency; no significant differences in dropout rates; few long-term medication trials and high relapse rates; failure to achieve remission in about 50% patients; study does not help identify patient characteristics which may be guide therapy selection (Behav Ther 1999 Winter;30:117 in Evidence-Based Medicine 1999 Sep-Oct;4(5):145)
    • cognitive behavioral therapy (CBT) associated with more rapid improvement than interpersonal psychotherapy; 220 patients meeting DSM-III-R criteria for bulimia nervosa randomized to CBT vs. interpersonal psychotherapy for 19 sessions over 20 weeks, follow-up at 1 year after treatment, 29% vs. 6% recovered (NNT 5), 48% vs. 28% remitted (NNT 5), 41% vs. 27% met community norms for eating attitudes and behaviors (NNT 8) (Arch Gen Psychiatry 2000 May;57(5):459 in JAMA 2000 Sep 20;284(11):1361)
    • lack of reduction in purging behavior by sixth CBT session predicts failure to respond to CBT; study of 140 patients who completed 18 sessions of CBT, 41% stopped binge eating or purging, patients who had not reduced purging by 70% or more by the sixth treatment session were more likely to fail CBT therapy (Am J Psychiatry 2000 Aug;157(8):1302 in Am Fam Physician 2001 Feb 1;63(3):536)
    • discussion of cognitive behavior therapy and evidence base for psychotherapies can be found in BMJ 2002 Feb 2;324(7332):288, commentary can be found in BMJ 2002 Jun 22;324(7352):1522
  • self-help manual may reduce some eating disorder symptoms in adults (level 2 [mid-level] evidence)
    • systematic review of 12 randomized and 3 controlled trials of manual-based pure self-help or guided self-help in adults with bulimia nervosa, binge eating disorder or eating disorder not otherwise specified
    • compared to waiting list
      • non-significant differences in abstinence from binging or purging
      • greater improvement in other eating disorder symptoms
      • greater improvement in psychiatric symptoms but not depression
      • greater improvement in interpersonal functioning
    • compared to other psychological therapies, no significant differences
    • Reference - systematic review last updated 2006 May 24 (Cochrane Library 2006 Issue 3:CD004191)
  • CBT-guided self-care appears as effective as family therapy for adolescents with bulimia nervosa or eating disorder not otherwise specified (level 2 [mid-level] evidence)
    • based on randomized trial with few significant differences
    • 85 adolescents with bulimia nervosa or eating disorder not otherwise specified recruited from eating disorder services in United Kingdom were randomized to family therapy vs. indivdiual CBT guided self-care supported by health professional
    • guided self-care group had significantly greater reduction in bingeing at 6 months but no significant differences at 12 months
    • no significant differences in other behavioral or attitudinal eating disorder symptoms
    • Reference - Am J Psychiatry 2007 Apr;164(4):591
  • family-based treatment might be more effective than supportive psychotherapy for achieving abstinence from binge-and-purge episodes (level 2 [mid-level] evidence)
    • based on randomized trial without blinding of outcome assessors
    • 80 patients aged 12-19 years with bulimia nervosa were randomized to 20 sessions of either family-based therapy or supportive psychotherapy over 6 months and followed for 6 months after end of treatment
    • follow-up completed by 71 patients (89%) at end of treatment and 68 patients (85%) 6 months later
    • comparing family-based therapy vs. supportive psychotherapy in intention to treat analysis
      • 39% (16 of 41) vs. 18% (7 of 39) remission (no binge eating or compensatory behavior in prior 4 weeks) at end of treatment (p = 0.049, NNT 5)
      • 41% vs. 21% partial remission (no longer meeting study entry criteria) at end of treatment (p = 0.06)
      • 29% (12 of 41) vs. 10% (4 of 39) remission at 6 months (p = 0.05, NNT 6)
      • 49% vs. 38% partial remission at 6 months (not significant)
    • Reference - Arch Gen Psychiatry 2007 Sep;64(9):1049

Medications :

  • potassium supplementation may be necessary
  • antidepressants
    • antidepressants clinically effective for bulimia nervosa; systematic review of 19 randomized trials of antidepressants vs. placebo for patients with bulimia nervosa; 6 trials with TCAs (imipramine, desipramine and amitriptyline), 5 with SSRIs (fluoxetine), 5 with MAOIs (phenelzine, isocarboxazid, moclobemide and brofaromine) and 3 with other antidepressants (mianserin, trazodone and bupropion); similar efficacy results for all drug classes, antidepressants effective with pooled relative risk for remission of binge episodes was 0.88 (95% CI 0.83-0.93, p < 0.001, NNT 9 for mean 8 weeks, 95% CI 6-16), relative risk for 50% reduction or more in binge episodes was 0.63 (95% CI 0.55-0.74, NNT 4 for mean 9 weeks, 95% CI 3-6), antidepressants associated with higher dropout rates due to adverse events (especially TCAs, less dropouts with fluoxetine); insufficient data to determine if antibulimic effects are independent of antidepressant effects; systematic review last updated 2003 Aug 11 (Cochrane Library 2003 Issue 4:CD003391), commentary can be found in ACP J Club 2002 May-Jun;136(3):106
    • antidepressants effective for patients with bulimia, but supporting evidence methodologically poor; systematic review and meta-analysis of 16 randomized trials with 1,300 bulimic patients; short-term remission in bulimic symptoms was statistically more likely on antidepressants than placebo, drop-out rates were high (about 33%) but no statistical difference between treatment groups, no difference in efficacy or tolerability could be demonstrated among different classes of antidepressants (Aust N Z J Psychiatry 2000 Apr;34(2):310 in BMJ 2000 May 27;320(7247):1484)
    • SSRIs have been recommended over tricyclic antidepressants on theoretical grounds of safety with respect to electrolyte disturbances and arrhythmias
    • fluoxetine (Prozac) FDA approved for moderate-to-severe bulimia, 60 mg/day more effective than standard 20 mg/day antidepressant dose, effective in both depressed + nondepressed patients (Monthly Prescribing Reference 1997 Jan:A-22)
    • fluoxetine but not guided self-help improved multiple outcomes (level 2 [mid-level] evidence) in randomized placebo-controlled trial of 91 patients in primary care, study limited by high dropout rate (Am J Psychiatry 2004 Mar;161(3):556 in BMJ 2004 Mar 13;328(7440):652)
  • antacids, H2 antagonists or proton pump inhibitors
  • topiramate (Topamax) may reduce binge and purge episodes short-term (level 2 [mid-level] evidence); comprehensive search found only 1 controlled trial; 69 patients with bulimia nervosa randomized to topiramate 25-400 mg/day (median 100 mg/day) vs. placebo for 10 weeks, 64 patients evaluated in intent to treat analysis, mean weekly number of binge or purge days reduced by 45% with topiramate vs. by 11% with placebo (p = 0.004) (J Clin Psychiatry 2003 Nov;64(11):1335 in Annals of General Psychiatry 2005 Feb 16;4:5)
  • ondansetron for 4 weeks reduced mean binge/vomit frequencies from 13.2 to 6.5 per week in preliminary randomized placebo-controlled trial of 26 patients (Lancet 2000 Mar 4;355(9206):792), editorial can be found in Lancet 2000 Mar 4;355(9206):769, commentary can also be found in Am Fam Physician 2000 Sep 1;62(5):1156
  • naltrexone (100 mg or 200 mg twice daily) associated with reduction in binge-purge symptoms (level 2 [mid-level] evidence) in randomized placebo-controlled crossover trial with 19 patients with bulimia or anorexia nervosa of bulimic subtype (Int Clin Psychopharmacol 1995 Sep;10(3):163)
  • proton pump inhibitor used in case report to correct hypokalemia and metabolic alkalosis associated with persistent self-induced vomiting (N Engl J Med 2002 Jan 10;346(2):140), commentary can be found in N Engl J Med 2002 Aug 1;347(5):373

Consultation and referral :

  • mental health specialist and/or primary care physician experienced in eating disorders
  • self-help manual based on cognitive behavior principles with continued contact with general practitioners had similar outcomes at 9 months compared to management by specialist clinic in randomized trial of 68 patients with bulimia referred to specialist clinic (Br J Gen Pract 2003 May;53(490):371)

Other management :

  • video feedback may reduce mealtime conflict in mothers with bulimia
    • 80 mothers with bulimia nervosa or similar eating disorder and infants ages 4-6 months were randomized to video-feedback interactional treatment vs. supportive counseling
    • both groups given guided cognitive behavior self-help for eating disorder
    • 77 mothers were followed up at infant age 13 months
    • 24% video-feedback group vs. 54% control group had episodes of marked or severe mealtime conflict (NNT 3.3)
    • Reference - Am J Psychiatry 2006 May;163(5):899

Follow-up :

  • electrolytes
  • urine pH
  • dental care

Prevention and Screening

Prevention :

  • no evidence to support programs to prevent eating disorders in children and adolescents; systematic review of 8 trials last updated 2002 Feb 8 (Cochrane Library 2002 Issue 2:CD002891)
  • school-based intervention may reduce purging or using diet pills to control weight
    • 10 middle schools randomized to intervention (Planet Health obesity prevention program to promote healthful nutrition and physical activity and reduce television viewing) vs. control
    • 480 girls ages 10-14 years followed up at 21 months
    • 2.8% girls in intervention schools vs. 6.2% girls in control schools reported purging or using diet pills to control weight in prior 30 days (p = 0.003, NNT 30)
    • Reference - Arch Pediatr Adolesc Med 2005 Mar;159(3):225, commentary can be found in Am Fam Physician 2005 Dec 1;72(11):2342
  • dissonance-inducing activities and healthy weight management prevention programs may reduce risk factors for eating disorders in adolescent girls
    • 481 adolescent girls with body dissatisfaction randomized to 1 of 4 programs
      • eating disorder prevention program with dissonance-inducing activities that reduce thin-ideal internalization
      • prevention program promoting healthy weight management
      • expressive writing control condition
      • assessment-only control condition
    • dissonance participants had significantly greater reductions in eating disorder risk factors and bulimic symptoms than 3 other groups
    • dissonance and healthy weight participants had significantly lower binge eating and obesity onset and reduced service utilization through 12 months than other 2 groups
    • Reference - J Consult Clin Psychol 2006 Apr;74(2):263
  • Internet-based cognitive behavior therapy program might reduce risk of onset of eating disorders in some high-risk groups of college age women (level 2 [mid-level] evidence)
    • based on subgroup analysis of randomized trial without intention-to-treat analysis and high dropout rates
    • 480 women ages 18-30 years with high weight and shape concerns and body mass index 18-32 kg/m 2 (but current eating disorder excluded) were randomized to Internet-based cognitive behavior therapy program (including moderated online discussions) vs. wait list control
    • 59 (12%) reported to be lost to follow-up, but outcomes reported for 391 (81%) at 1 year and 233 (49%) at 2 years
    • no significant differences in onset of eating disorders over 3 years in overall analysis
    • 43 women developed eating disorders including bulimia nervosa, subclinical bulimia nervosa, binge eating disorder, or entering therapy for eating disorder (diagnosis not stated)
    • comparing intervention vs. control in subgroup with body mass index ≥ 25 kg/m 2 at baseline
      • 0% vs. 4.7% developed eating disorders at 1 year
      • 0% vs. 11.9% developed eating disorders at 2 years
    • comparing intervention vs. control in subgroup using diuretics, laxatives, diet pills or vomiting at baseline
      • 3.6% vs. 8% developed eating disorders at 1 year
      • 10.1% vs. 19% developed eating disorders at 2 years
    • not clear if any of these differences are statistically significant
    • Reference - Arch Gen Psychiatry 2006 Aug;63(8):881
  • eating regular family meals may reduce risk of developing eating disorders in adolescent girls (level 2 [mid-level] evidence)
    • based on subgroup analysis of longitudinal follow-up study
    • 1,363 adolescent girls completed in-class surveys and anthropometric measures and completed survey by mail 5 years later
    • family meals ≥ 5/week associated with lower risk for extreme weight control behaviors such as self-induced vomiting, use of laxatives, diet pills, or diuretics (odds ratio 0.71, 95% CI 0.52-0.97)
    • no significnat association in 1,130 boys
    • Reference - Arch Pediatr Adolesc Med 2008 Jan;162(1):17 full-text

Screening :

  • COFFS acronym may be useful for screening for eating disorders
    • 5 questions
      • Do you worry you have lost Control over how much you eat?
      • Have you recently lost more than One stone in a 3 month period (one stone = 14 pounds = 6.3 kg)?
      • Do you believe yourself to be Fat when others say you are too thin?
      • Would you say that Food dominates your life?
      • Do you make yourself Sick because you feel uncomfortably full?
    • 2 or more positive answers suggests eating disorder
    • validation of this screening questionnaire done by comparing 116 women 18-40 with confirmed anorexia or bulimia in eating disorders clinic with 96 controls, so unknown if applicable to general population or younger women
    • Reference - BMJ 1999 Dec 4;319(7223):1467
    • SCOFF questionnaire had 85% sensitivity, 90% specificity, 24% positive predictive value and 99.3% negative predictive value for eating disorder in study of 341 women (BMJ 2002 Oct 5;325(7367):755), correction can be found in BMJ 2002 Dec 7;325(7376):1331, commentary can be found in Evidence-Based Medicine 2003 May-Jun;8(3):90

References including Reviews and Guidelines

Reviews :

Guidelines :

Patient Information

Patient information :