Bulimia Nervosa

Definition/Description

A condition during which a person eats a large amount of food in a short amount of time (binges), then uses some method of purging to avoid weight gain. Methods of purging include self-induced vomiting, use of laxatives or diuretics, and excessive exercise. [1]


Criteria for Bulimia Nervosa According To Cleveland Clinic[2]:

[3]
  1. Recurrent episodes of binge eating characterized by both:
  • 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
  • A sense of lack of control over eating during the episode, defined by a feeling that one cannot stop eating or control what or how much one is eating

2. Recurrent inappropriate compensatory behavior to prevent weight gain by:

  • Self-induced vomiting
  • Misuse of laxatives, diuretics, enemas, or other medications
  • Fasting
  • Excessive exercise

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

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

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


Types of Bulimia Nervosa According to Cleveland Clinic[2]:

  • 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 inappropriate compensatory behavior but has not regularly engaged in self-induced vomiting or misused laxatives, diuretics, or enemas.

Prevalence

The incidence of people suffering from bulimia has increased over the last 30-40 years. Around 1 to 2% of females in late adolescence and adult women meet the diagnostic criteria for bulimia nervosa. [4] About 80% of people with bulimia nervosa are female [5] and 1.5% of American women suffer from bulimia nervosa in their lifetime.[6]. The Standard mortality ratio (SMR) for Bulimia Nervosa is 1.93.[7]

Characteristics/Clinical Presentation

Bulimia can affect anyone; male, female, young, old, and all races. These patients can present with normal weight or they may be underweight or overweight. The patient may use pills (diet pills, diuretics, or laxitives). They may often take trips to the bathroom after eating (suggested that they use this time to purge after a meal) and may exercise despite weather, injury, or energy levels to control their weight. [1]

Signs of binging include[5]:

  • The disappearance of large amounts of food in a short time period
  • Finding wrappers/containers of consumed food around the person's living environment

Signs of purging include[5]:

  • Frequent trips to the bathroom after meals
  • Signs or smells of vomiting
  • Evidence of use of laxatives/diuretics (wrappers, containers, etc.) 
  • Main focus and concern on weight loss, dieting, and controlling their food (intake/outtake)
  • Excessive and rigid exercise routines (continued despite weather, illness, injury, energy levels)
  • Rigid schedules that allow time for binge/purge cycles
  • Withdrawal from normal activities

Signs of self-induced vomiting include[8]:

  • Swelling of the patient's cheeks/jaws
  • Calluses or scrapes on the knuckles
  • Clear-looking teeth
  • Broken blood vessels in the eyes

May also present with other mental health problems such as depression, anxiety, substance abuse, distorted body image (thoughts and verbal expressions of hating body, image of being fat despite thin appearance, and fear of gaining weight), and reports from family and friends on activity not "normal" for the person (i.e. moody, sad, unsocialable)

Physical Signs and Symptoms can include[9]:

  • Weight loss/gain
  • Muscle weakness and/or myopathy
  • Chronic fatigue
  • Dehydration or rebound water retention
  • Pitting edema
  • Discoloration of teeth
  • Broken blood vessels in eyes
  • Enlarged salivary glands
  • Scrapes/calluses on dorsums of hands/fingers
  • Inability to tolerate cold
  • Irregular or absent menstrual cycles
  • Delay in menses in young girls
  • Dry skin and hair
  • Hair loss
  • Lanugo growth over entire body
  • Brittle nails
  • Reports of heartburn, gas, constipation, or diarrhea
  • Slow heart rate and low blood pressure

Behavioral signs and symptoms can include[9]:

  • Preoccupation with weight, food, calories, fat grams, dieting, clothing size, and body shape
  • Personality changes (i.e. mood swings and irritability that may not have been present before)
  • Binging and purging behavoirs or food restriction behaviors
  • Frequent trips to the bathroom after meals
  • Distored body images (both thoughts and verbal expressions of dissatisfaction, despite thin body)
  • Excessive and rigid exercise routine
  • Use of pills or other drugs to control weight (i.e. diuretics, laxatives, enemas, etc.)

Associated Co-morbidities [8]

Often times bulimia nervosa is also associated with mental health disorders, such as Depression, Anxiety and Substance Abuse. Nearly half of bulimia patients have a comorbid mood disorder,[10] more than half of bulimia patients have comorbid anxiety disorders[10] and nearly 1 in 10 bulimia patients have a comorbid substance abuse disorder, usually alcohol use.[10] 

Medications

Anti-depressant medications have been found to be effective, especially when combined Cognitive Behavior Therapy, versus the medication only or therapy only. [11]

SSRIs tend to be used initially, as they tend to be both effective and safe. Fluoxetine (Prozac) is the only FDA-approved anti-depressant medication for treatment of bulimia. Bupropion (Wellbutrin) has been proven to be effective, however, contraindicated because of its association with seizures in patients who purge. Anti-depressants are often used because of the accompanying psychological symptoms (i.e. anxiety, depression, etc.); however, studies have found these medications to be effective in patients who do not have anxiety and/or depression co-morbidities. This suggests that anti-depressants can specially treat symptoms of bulimia (i.e. binges, purging, pre-occupation with body image). [12][11]

Other medications that are gaining recognition for effectiveness include topiramate and ondansetron (Zofran). Topiramate is an anti-convulsant that has been found to be effective in decreasing the frequency of binging and purging , as well as improving the associated psychological co-morbidities. Mild to moderate adverse side effects have been found with using topiramate in patients with bulimia; however this finding was based on a small study and would need further investigation. Ondansetron is an anti-emetic used in cancer patients to help prevent nausea and vomiting. Findings are based on small studies, further investigation is needed to address all aspects of how this anti-emetic could effectively treat bulimia.

More studies are needed on long-term effectiveness of pharmacological treatment of bulimia; also, few studies have been done on the effects of medications of adolescents, as most studies have looked at effects on adults. One study (a study on adults) performed was flawed by “attrition in both study drug (fluoxetrine) and placebo arms.” The study found “a lower rate of relapse for the fluoxetrine group, but the investigators noted a worsening on all measures of efficacy over time. They concluded that pharmacotherapy alone may not be adequate treatment after acute response for most patients… less than 20% acute phase remission rate” was also found in this study. This finding on remission rates has been found to be consistent with data from other studies, suggesting “that the vast majority of responders (i.e. a 50% or greater decrease in weekly vomiting episodes) were still binging and purging at the beginning of maintenance therapy, indicating that the idea of relapse prevention may be dubious in most trial participants.”[12]

Diagnostic Tests/Lab Tests/Lab Values

In diagnosing bulimia nervosa, patients must meet specific criteria. Patients can NOT simultaneously meet the diagnostic criteria for anorexia nervosa.  To meet the bulimia nervosa criteria, a patient binges and then engages in "inappropriate compensatory behavior at least twice weekly for at least three months." [4]

Other exams, such as dental exams, can help with identifying signs of excessive vomiting. Dental exams may reveal decrease enamel, cavities, and gum infection. Metabolic panels can show electrolyte imbalances (i.e. hypokalemia) and help identify dehydration. [13]

Causes

There have been no specific things proven to cause bulimia. Triggers to bulimia nervosa have been suggested, including dieting, stress, emotions, and the need for control (to ease stress or anxiety in a person's life). Factors that are suggested to contribute to bulimia include culture, family history, stressful life event, personality, and biology. [1]Rarely it is one factor in causing bulimia, often it is found that genetics, psychological factors, family and societal pressures, and/or cultural influences. [13] A recent study by Luther et al[14] reported that glucagon-like peptide 1 (GLP1) levels are low in patients with bulima nervosa.[15][16]

Systemic Involvement

Complications from bulimia can include: 

  • "Tears in the esophagus
  • Inflammation of the throat
  • Enlarged glands near cheeks
  • Pancreatitis
  • Peptic ulcers
  • Stomach damage
  • Constipation and hemorrhoids
  • Dental cavities and gum infections
  • Dehydration and electrolyte imbalances
  • Irregular heartbeat, heart failure, and death can occur secondary to the imbalances due to loss of essential nutrients and electrolyte imbalances."[13][17]

A diagram from womenshealth.gov, showing how bulimia can result in complications throughout your body:

Bulimiafaqdia.jpg

Medical Management (current best evidence)

Typical treatment for people with bulimia nervosa includes a multi-disciplinary approach; a treatment team usually involves a primary care physician, a dietician/nutritionist, a mental health professional, as well as nurses and other supportive medical personnel. [4]

The treatment process: the initial assessment addresses the patient's past medical history, current symptoms, current physical and mental status, the way the patient controls their weight, and any psychiatric issues/disorders (i.e. depression, anxiety, etc.). A physician and dietician are consulted, developing a diagnosis and place of care for the patient. Most people with bulimia are treated on an outpatient basis; however their treatment is coordinated between their physician, psychotherapist, and dietician. [4]

Some patients choose to be treated without mental health professionals, while others only recieve treatment from mental health professionals. Psychotherapy includes cognitive-behavoiral therapy, behavior therapy, family therapy, and interpersonal psychotherapy. Some patients are successful with short-term treatments such as these, others require long-term.[4]

Some patients are treated with psychopharmacology. Psychiatric medications have been found to be successful in treating patients with bulimia; these medications often include anti-depressants. [4]

Nutritional counseling is also a treatment option and a vital component for patients diagnosed with an eating disorder. Dieticians serves as educatiors to both the patient and their families. Dieticians help patients with bulimia to normalize their eating behaviors. [4]

Some patients diagnosed with bulimia have complications secondary to their disorder, thus requiring treatment beyond that for their eating disorder. These treatments vary according to the severity of systemic involvement and complications.[4]


"Indications for Hospitalization (according to the Cleveland Clinic's Continuing Education Center):

  • Weight <75% of individually estimated healthy weight
  • Rapid, persistent decline in oral intake or weight despite maximally intensive outpatient interventions
  • Prior knowledge of weight at which physical instability is likely to occur in the particular patient
  • Serious physical abnormalities:
  1. Electrolyte or metabolic abnormalities
  2. Hematemesis
  3. Vital sign changes including orthostatic hypotension and heart rate <40 bpm or >110 bpm
  4. Inability to sustain body core temperature
  • Comorbid psychiatric illness (suicidal, depressed, unable to care for self, etc.)"[18]


In severe cases of bulimia, patients require in-patient treatment. This treatment provides the patient with a more structured environment, providing treatment and monitoring twenty-four hours a day, every day of the week. These programs are often arranged in a "step up" and "step down" levels allowing patients to progress (or for some, regress) in their treatment accordingly. For patients that need it, long-term in-patient programs are also available (i.e. residential treatment programs). [4]


Jayasekara performed a Cochrane Review in efforts to identity the best practice in medically treating patients with bulimia nervosa. "Best Practice Recommendations:

  • Cognitive behaviour therapy (CBT) for bulimia nervosa (CBT-BN), a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. This course of treatment should be for 16-20 sessions over 4 to 5 months. (Grade A)
  • When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered. (Grade B)
  • Interpersonal psychotherapy should be considered as an alternative to CBT, but patients should be informed it takes eight to 12 months to achieve results comparable with CBT. (Level B)
  • Patients should be informed that antidepressant drugs can reduce the frequency of binge eating and purging, but the long-term effects are unknown. (Grade B)
  • SRIs, specifically fluoxetine are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability and reduction of symptoms. (Grade B)
  • The combination of CBT with antidepressant drugs is superior to antidepressant drugs on their own. (Grade B)”[19]

Physical Therapy Management (current best evidence)

Physical therapists working under the practice patterns of "4A Primary Prevention/Risk Reduction for Skeletal Demineralization, 4B Impaired Posture, 4C Impaired Muscle Performance (especially with malnutrition and fluid/electrolyte disturbances), 6A Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders, 6B Impaired Aerobic Capacity/Endurance Associated with De-conditioning, 7A Primary Prevention/Risk Reduction for Integumentary Disorders (malnutrition)" can help in the treatment of patients with bulimia nervosa. [20]

According to the Guide for Physical Therapist Practice, physical therapists work preventatively or retrospectively with patients suffering from complications secondary to eating disorders. Some physical therapists may treat a person, who in addition to having an orthopedic problem for example, also has an eating disorder (whether known to the therapist or not). [21]

Physical therapists can help with early screening and detection of and for eating disorders. The more informed a clinician can be, the more they are able to provide appropriate evaluations and interventions for their patients, helping to decrease the consequences and complications of the eating disorder. Recognizing at risk patient populations can also help with early detection; i.e. young, female athletes are at a higher risk for the female athlete triad. [21]

At risk patient populations can include females, those with a perfectionist personality, Caucasians, personal and/or family history of eating disoders or obesity, athletes, and patients with a history of trauma or sexual abuse. As a physical therapist, recognizing and being aware of patients with a distorted body image or distorted eating habits is also important. Some athletes who compete under-weight classes or must build up their bodies for competition can be at risk for developing eating disorders. [9]

Some questions to consider as physical therapists screening for eating disorders include:

  • "Are you satisfied with your eating patterns?
  •  Do you force yourself to exercises, even when you don’t feel well?
  •  Do you exercise more when you eat more?
  •  Do you think you will gain weight if you stop exercising for a day or two?
  •  Do you exercise more than once a day?
  •  Do you take laxatives/diuretics/any other pills as a way to control your weight or shape?
  •  Do you ever eat in secret (i.e. in closets or bathrooms to avoid being seen eating)?
  •  Are there days when you don’t eat anything?
  •  Do you ever make yourself throw up after eating as a way to control your weight?"[9]

The SCOFF Questionaire, mentioned by Hay in Understanding Bulimia, may be a useful tool in the physical therapy setting. "The SCOFF Questionaire:

  • Do you ever make yourself Sick because you feel uncomfortably full?
  • 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?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?
  • One point is given for every ‘yes’ answer. A score of two or more indicates possible anorexia nervosa or bulimia nervosa.
    *Note: 1 stone is approximately 6.35 kg"[22]

Bulimia impacts a patient's fluid and electrolyte balance, putting them at risk for fluid depletion and ineffective temperature regulation. These, in addition to the use of self-induced vomiting or laxatives, can put the patient at a very high risk for dehydration and loss of potassium. Patients with these complications may initially present with muscle cramping, fatigue, as well as orthostatic hypotension. A physical therapist may have to hold treatment of their patient until fluid and electrolyte imbalances are normalized. It is important that the physical therapist encourage their patient to drink plenty of fluids and reduce their activity until levels are normalized. Patients with severe dehydration and electrolyte imbalances may present with confusion, disorientation, uncoordinated movements. These patients should be sent for immediate medical attention. Another consideration for physical therapists is the effects bulimia can have on bone; patients presenting with an orthopedic problem may also have bulimia. Often times, bone integrity is weakened, which is something as a therapist should be aware of if thrust manipulations are being considered in the treatment plan. [21]

Differential Diagnosis [23]

  • Central Nervous System pathologies (i.e. brain tumors) can stimulate bulimia.
  • Kluver-Bucy Syndrome (symptoms include hyperphagia, hypersexuality, and compulsive licking and biting) and Klein-Levin Syndrome (more common in men; symptoms include hyperphagia and period hypersomnia) should be ruled out.
  • Patients must be screened carefully to correctly diagnose bulimia, versus the purge subtype of anorexia nervosa.
  • Patients with borderline personality disorder may present with binge eating tendencies; however, these patients will not meet the other diagnostic criteria for bulimia.

Case Reports

Schapman-Williams AM, Lock J. Using Cognitive-Behavioral Therapy to Treat Adolescent-Onset Bulimia Nervosa: A Case Study. Clinical Case Studies. December 2007; 6(6):508-524. 

  • Abstract: "This case study describes the treatment of an adolescent female, referred to as Susan, who presented for evaluation at the Eating Disorders Clinic of Child and Adolescent Psychiatry at Stanford University. Susan presented with symptoms of body image disturbance, dietary restriction, binge eating, self-inducted vomiting, and overexercise, and was diagnosed with bulimia nervosa (BN). She was treated with 20 sessions of manualized cognitive-behavioral therapy (CBT) for BN adjusted for adolescents. Susan’s progress throughout treatment is detailed in this case study report. Results lend support to a scant body of case series studies attesting to the efficacy of CBT for use with adolescents with BN. Large-scale, randomized studies are needed to corroborate preliminary conclusions that have been promulgated in this case study."
  • Available online at: http://ccs.sagepub.com/cgi/content/abstract/6/6/508


Schmidt U, et al. A Randomized Controlled Trial of Family Therapy and Cognitive Behavior Therapy Guided Self-Care for Adolescents with Bulimia Nervosa and Related Disorders. Am J Psychiatry. 2007; 164:591-598.

  • Abstract: Objective: To date no trial has focused on the treatment of adolescents with bulimia nervosa. The aim of this study was to compare the efficacy and cost-effectiveness of family therapy and cognitive behavior therapy (CBT) guided self-care in adolescents with bulimia nervosa or eating disorder not otherwise specified. Method: Eighty-five adolescents with bulimia nervosa or eating disorder not otherwise specified were recruited from eating disorder services in the United Kingdom. Participants were randomly assigned to family therapy for bulimia nervosa or individual CBT guided self-care supported by a health professional. The primary outcome measures were abstinence from binge eating and vomiting, as assessed by interview at end of treatment (6 months) and again at 12 months. Secondary outcome measures included other bulimic symptoms and cost of care. Results: Of the 85 study participants, 41 were assigned to family therapy and 44 to CBT guided self-care. At 6 months, bingeing had undergone a significantly greater reduction in the guided self-care group than in the family therapy group; however, this difference disappeared at 12 months. There were no other differences between groups in behavioral or attitudinal eating disorder symptoms. The direct cost of treatment was lower for guided self-care than for family therapy. The two treatments did not differ in other cost categories. Conclusions: Compared with family therapy, CBT guided self-care has the slight advantage of offering a more rapid reduction of bingeing, lower cost, and greater acceptability for adolescents with bulimia or eating disorder not otherwise specified.
  • Available online at: http://ajp.psychiatryonline.org/cgi/content/full/164/4/591?maxtoshow=&hits=10&RESULTFORMAT=1&title=Bulimia&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&fdate=//&resourcetype=HWCIT


Resources

In a study by Carei et al, an individualized yoga treatment program was established for patients with eating disorders (including anorexia nervosa, bulimia nervosa, and other eating disorders). This study, while small, did find success, the patients' preoccupation with food was decreased after their yoga sessions and no negative effect was found on the patients' BMI. The yoga program was used in addition to standard care[24].  An abstract to this study can be accessed from: http://www.ncbi.nlm.nih.gov/pubmed/20307823

References

  1. 1.0 1.1 1.2 Office on Women's Health in the U.S. Department of Health and Human Services. 2009. Available from: U.S. Department of Health and Human Services, Web site: http://www.womenshealth.gov/faq/bulimia-nervosa.cfm. Accessed February 2010.
  2. 2.0 2.1 Franco, Kathleen N. Eating Disorders. Cleveland Clinic Center for Continuing Education Website. 2009. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/
  3. Professor Janet Treasure. Bulimia Nervosa. Available from: http://www.youtube.com/watch?v=NXm59j53SmA
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Academy for Eating Disorders. Website: http://www.aedweb.org/eating_disorders/index.cfm. Accessed February 2010.
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  7. Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731.
  8. 8.0 8.1 Office on Women's Health in the U.S. Department of Health and Human Services. 2009. Available from: U.S. Department of Health and Human Services, Web site: http://www.womenshealth.gov/faq/bulimia-nervosa.cfm. Accessed February 2010.
  9. 9.0 9.1 9.2 9.3 Goodman CC & Snyder TE Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, Missouri: Saunders Elsevier; 2007.
  10. 10.0 10.1 10.2 Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299.
  11. 11.0 11.1 Williams P., Goodie J., Motsinger C.. Treating Eating Disorders in Primary Care. American Family Physician. 2008 Jan 15;77(2): 187-95. In: ProQuest Health and Medical Complete [database on the Internet] [cited 2010 Apr 5]. Available from: http://www.proquest.com/; Document ID: 1432620761.
  12. 12.0 12.1 Trunko M., Kaye W.. Pharmacological Treatment of Bulimia Nervosa: A Review of Available Medications. Psychiatric Times. 2008 May 1;25(6): 52,56-58. In: ProQuest Nursing & Allied Health Source [database on the Internet] [cited 2010 Apr 5]. Available from: http://www.proquest.com/; Document ID: 1769161331.
  13. 13.0 13.1 13.2 Van Voorhees BW, Zieve D. Bulimia: MedlinePlus Medical Encyclopedia. Last Updated Jan. 25, 2010. Available from: U.S. National Library of Medicine and the National Institutes of Health, Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000341.htm. Accessed February 2010.
  14. Lutter M, Bahl E, Hannah C, Hofammann D, Acevedo S, Cui H, et al. (2017) Novel and ultra-rare damaging variants in neuropeptide signaling are associated with disordered eating behaviors. PLoS ONE 12(8): e0181556. https://doi.org/10.1371/journal.pone.0181556
  15. Dossat AM, Bodell LP, Williams DL, Eckel LA, Keel PK (2015) Preliminary examination of glucagon-like peptide-1 levels in women with purging disorder and bulimia nervosa. Int J Eat Disord 48: 199–205. pmid:24590464
  16. Naessen S, Carlstrom K, Holst JJ, Hellstrom PM, Hirschberg AL (2011) Women with bulimia nervosa exhibit attenuated secretion of glucagon-like peptide 1, pancreatic polypeptide, and insulin in response to a meal. Am J Clin Nutr 94: 967–972. pmid:21813805
  17. United States Department of Health and Human Services- Substance Abuse and Mental Health Services Administration, Available at: http://mentalhealth.samhsa.gov/publications/allpubs/ken98-0047/default.asp#4. Accessed February 2010.
  18. Franco, Kathleen N. Eating Disorders. Cleveland Clinic Center for Continuing Education Website. 2009. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/
  19. Jayasekara R.. Bulimia Nervosa: Management. Evidence Summaries - Joanna Briggs Institute. 2007 Oct 10. In: Evidence-Based Resources from the Joanna Briggs Institute [database on the Internet] [cited 2010 Apr 5]. Available from: http://www.proquest.com/; Document ID: 1451761891.
  20. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Virginia: American Physical Therapy Association; 2003.
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  24. Carei TR, et al. Randomized Controlled Clinical Trial of Yoga in the Treatment of Eating Disorders. J Adolesc Health. April 2010; 46 (4): 346-51.