Internet Mental Health


Diagnostic Features of Bulimia Nervosa

Terrified of Being Fat Is obsessed with weight loss and phobic of weight gain "I absolutely dread being fat or flabby."
Hates Own Body Shape and Size Overvalues thinness; hates own body shape and size "I'm fat and I can never be too thin."
Compulsively Attempts To Lose Weight Attempts to lose weight by compulsive dieting, exercising, self-induced vomiting, laxative/diuretic abuse "To lose weight, I'm always dieting, exercising, vomiting, or using laxatives/water pills (diuretics)."
Dieting Backfires and Triggers Binge Eating Attempts at dieting backfire and trigger compulsive binge eating "Sometimes when I start eating I can't stop until I get sick. "
Binge Eating Causes Harm Repeated vomiting causes dangerous electrolyte imbalance and other physical complications "My vomiting is causing serious problems."


    This disorder consists of overvaluing thinness, developing a phobia about being fat, obsessing about it, and compulsively dieting. However, this compulsive dieting fails and triggers cycles of overeating followed by vomiting or use of purgatives. It may last from a few months to many years.


Emotional Distress (Negative Emotion) :

  • Normal weight, yet obsessed with weight loss, phobic of weight gain, and markedly dissatisfied with own body size and shape.

  • Food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse); caloric restriction.

  • May cycle between having anorexia nervosa (caloric restriction), and having bulimia nervosa (food binging).

  • 30% develop Substance Abuse or Dependence (especially alcohol or stimulants).

  • Many develop Borderline Personality Disorder or some other personality disorder.

  • When severe, may develop anxiety.

Medical :

  • Illness denial is common.

  • Self-induced vomiting can cause: dental enamel erosion, fluid & electrolyte disturbances, esophageal tears, gastric rupture, and cardiac arrhythmias.

  • Excessive exercise; menstrual irregularity; gastrointestinal symptoms; rectal prolapse.

SAPAS Personality Screening Test

Individuals with this disorder would have a significant impairment in the behaviors that are displayed in red :

Most of the time and in most situations:

      In general, do you have difficulty making and keeping friends?
      Would you normally describe yourself as a loner?
      In general, do you trust other people? ("No")
      Do you normally lose your temper easily?
      Are you normally an impulsive sort of person?
      Are you normally a worrier?
      In general, do you depend on others a lot?
      In general, are you a perfectionist?

7-Question Well-Being Screening Test (By P. W. Long MD, 2020

Individuals with this disorder would have a significant impairment in the behaviors that are displayed in red :

      Agreeableness: I was kind and honest.
      Conscientiousness: I was diligent and self-disciplined.
      Openness/Intellect: I showed good problem-solving and curiosity.
      Sociality: I was gregarious, enthusiastic, and assertive.
      Emotional Stability: I was emotionally stable and calm. (Instead was obsessed with weight loss, terrifed of weight gain, compulsively attempted to lose weight, attempts at dieting backfired and triggered compulsive binge eating, overvalued thinness, hated own body shape and size)
      Physical Health: I was physically healthy. (Instead had potentially dangerous physical complications from repeated vomiting)
      Role Functioning: I functioned well socially and at school/work.

How often in the past week did you do each of these 7 behaviors:

Fear, Phobia, Obsession, Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Phobia:
    If fear about about a specific object or situation becomes excessive, it is defined as a phobia. This phobic fear is out of proportion to the actual danger posed by the specific object or situation, and this phobic fear causes significant distress or disability. In bulimia nervosa, the individual develops a phobia about gaining weight.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. As in anorexia nervosa, in bulimia nervosa the individual spends much of the time being obsessed with thinness, and being phobic of weight gain.

  • Compulsion:
    If the individual develops a superstitious ritual aimed at reducing the anxiety associated with the obsession; this is defined as a compulsion. A compulsion is a fear-relieving avoidance behavior. The individual feels driven to perform these compulsions. Unlike individuals with anorexia nervosa, attempts at compulsive dieting in bulimia nervosa backfire and trigger compulsive binge eating. This binge eating triggers more compulsive dieting behaviors (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise). This compulsive dieting-binging cycle becomes very difficult to stop. Repeated vomiting causes serious body electrolyte disturbances and physical complications. Many individuals with bulimia nervosa have a previous history of anorexia nervosa.

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Diagnose Bulimia Nervosa

Diagnose Eating Disorders

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Bulimia Nervosa 307.51

This diagnosis is based on the following findings:
  • Recurrent episodes of binge eating (still present)
  • The disturbance does not occur exclusively during episodes of anorexia nervosa
  • Adopted extreme measures to prevent weight gain (still present)
  • Binge eating and extreme measures to prevent weight gain occurred once/week for at least 3 months (still present)
  • Self-evaluation was unduly influenced by body shape and weight (still present)

Treatment Goals:

  • Goal: prevent recurrent episodes of binge eating.
    If this problem worsened: Her shame over binge eating will increase, as will her negative self-evaluation and negative mood.

  • Goal: prevent recurrent inappropriate compensatory behaviors to prevent weight gain.
    If this problem worsened: Her purging behaviors (e.g., vomiting, misuse of diuretics) could result in medically serious fluid and electrolyte disturbances. Sometimes severe vomiting results in esophageal tears, gastric rupture, or cardiac arrhythmias.

  • Goal: prevent disturbance in self-perceived weight or shape.
    If this problem worsened: Her self-esteem will become highly dependent on her perception of her body shape and weight. Weight loss will become valued as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain will be perceived as an unacceptable failure of self-control.

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Diagnostic Features

Bulimia Nervosa is characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives. As in Anorexia Nervosa, This disorder is characterized by an obsession with thinness, and a phobic fear of getting fat. Unlike individuals with Anorexia Nervosa, dieting in Bulimia Nervosa backfires and triggers compensatory binge eating. This binge eating, in turn, triggers inappropriate compensatory behaviors to prevent weight gain (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise). This food restriction, in turn, triggers more binge eating, and the binging-food restriction-binging cycle becomes compulsive and very difficult to stop. Repeated vomiting is likely to give rise to disturbances of body electrolytes and physical complications. There is often, but not always, a history of an earlier episode of Anorexia Nervosa, the interval ranging from a few months to several years.

Individuals with Bulimia Nervosa and Anorexia Nervosa share many similar features. In both disorders, individuals have an obsession with weight loss, a phobia of weight gain, and marked dissatisfaction with their body size and shape. Both disorders can have self-imposed caloric restriction, food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse). Some individuals cycle back and forth between Anorexia and Bulimia. Anorexic individuals restrict their caloric intake far more than Bulimic individuals do; thus Anorexics are pathologically thin, whereas many Bulimics have a normal weight. Bulimic individuals binge more than Anorexic individuals. Bulimia Nervosa is most common in women in their 20s and 30s.

Historically, eating disorders were a medical rarity prior to World War I. Then, after fashion magazines were introduced, the incidence of eating disorders shot up. Thus the current epidemic of eating disorders started after World War I in America, spread to Europe, and only after World War II spread to Asia. In Canada's far north, eating disorders were historically unknown in previous generations of aboriginals. The current older aboriginal generation was largely protected from Western influences by a language barrier, but younger aboriginals now speak English. Historically, for the first time, eating disorders are starting to appear in young aboriginals. Thus exposure to Western culture appears to be causal in the development of eating disorders.


One study of bulimic women, 5 to 10 years after therapy, found that about 50% had complete remissions, 30% had partial remissions, and about 20% had a chronic course without remission. Another study of bulimic women, 7-9 years following therapy, found that 61.2% had complete remissions, 10.1% suffered from subthreshold bulimia or anorexia, and 28.9% still had bulimia. This study found that the social adaptation of the women was quite good with regard to work, household and living conditions.

Effective Therapies

Remission rates are 39% for cognitive behavioral therapy (CBT), and only 20% for fluoxetine (the only medication licenced for this disorder). The addition of fluoxetine to CBT does not significantly improve the outcome. One major study found that (intent-to-treat) remission rates were: 22% (fluoxetine), 26% (placebo), 50% (CBT+fluoxetine), and 61% (CBT+placebo). Self-help manuals are helpful. Patient and family support groups are also helpful. CBT is better than other therapies, and better than no treatment, at reducing binge eating.

Ineffective therapies

Vitamins, and dietary supplements are ineffective for this disorder.

Trustworthy Research (

A Dangerous Cult

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Rating Scales

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Diagnostic Features of Bulimia Nervosa

Terrified of Becoming Fat
Hates Own Body Shape and Size
Compulsively Attempts To Lose Weight
Dieting Backfires and Triggers Binge Eating
Binge Eating Causes Harm

Diagnostic Criteria

Bulimia Nervosa F50.2 - ICD10 Description, World Health Organization

A syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives. This disorder shares many psychological features with anorexia nervosa, including an overconcern with body shape and weight. Repeated vomiting is likely to give rise to disturbances of body electrolytes and physical complications. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval ranging from a few months to several years.
Bulimia Nervosa - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with bulimia nervosa needs to meet all of the following criteria:

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

    • 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 (e.g., a feeling that one cannot stop eating or control what or how much one is eating.

  • 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.

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

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

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

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Treatment Guidelines

Summary Of Practice guideline for the treatment of patients with eating disorders. - American Psychiatric Association (2006)

Rating Scheme for the Strength of the Recommendations

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence:

  • [I] Recommended with substantial clinical confidence.

  • [II] Recommended with moderate clinical confidence.

  • [III] May be recommended on the basis of individual circumstances.

Choice of Specific Treatments for Bulimia Nervosa

The aims of treatment for patients with bulimia nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical complications of bulimia nervosa; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse.

  1. Nutritional Rehabilitation Counseling

    A primary focus for nutritional rehabilitation is to help the patient develop a structured meal plan as a means of reducing the episodes of dietary restriction and the urges to binge and purge [I]. Adequate nutritional intake can prevent craving and promote satiety [I]. It is important to assess nutritional intake for all patients, even those with a normal body weight (or normal BMI), as normal weight does not ensure appropriate nutritional intake or normal body composition [I]. Among patients of normal weight, nutritional counseling is a useful part of treatment and helps reduce food restriction, increase the variety of foods eaten, and promote healthy but not compulsive exercise patterns [I].

  1. Psychosocial Interventions

    It is recommended that psychosocial interventions be chosen on the basis of a comprehensive evaluation of the individual patient that takes into consideration the patient's cognitive and psychological development, psychodynamic issues, cognitive style, comorbid psychopathology, and preferences as well as patient age and family situation [I]. For treating acute episodes of bulimia nervosa in adults, the evidence strongly supports the value of CBT as the most effective single intervention [I]. Some patients who do not respond initially to CBT may respond when switched to either interpersonal therapy (IPT) or fluoxetine [II] or other modes of treatment such as family and group psychotherapies [III]. Controlled trials have also shown the utility of IPT in some cases [II].

    In clinical practice, many practitioners combine elements of CBT, IPT, and other psychotherapeutic techniques. Compared with psychodynamic or interpersonal therapy, CBT is associated with more rapid remission of eating symptoms [I], but using psychodynamic interventions in conjunction with CBT and other psychotherapies may yield better global outcomes [II]. Some patients, particularly those with concurrent personality pathology or other co-occurring disorders, require lengthy treatment [II]. Clinical reports suggest that psychodynamic and psychoanalytic approaches in individual or group format are useful once bingeing and purging improve [III].

    Family therapy should be considered whenever possible, especially for adolescent patients still living with their parents [II] or older patients with ongoing conflicted interactions with parents [III]. Patients with marital discord may benefit from couples therapy [II].

    A variety of self-help and professionally guided self-help programs have been effective for some patients with bulimia nervosa [I]. Several innovative online programs are currently under investigation and may be recommended in the absence of alternative treatments [III]. Support groups and 12-step programs such as Overeaters Anonymous may be helpful as adjuncts in the initial treatment of bulimia nervosa and for subsequent relapse prevention, but they are not recommended as the sole initial treatment approach for bulimia nervosa [I].

    Issues of countertransference, discussed above with respect to the treatment of patients with anorexia nervosa, also apply to the treatment of patients with bulimia nervosa [I].

  1. Medications
    1. Initial Treatment

      Antidepressants are effective as one component of an initial treatment program for most bulimia nervosa patients [I], with SSRI treatment having the most evidence for efficacy and the fewest difficulties with adverse effects [I]. To date, fluoxetine is the best studied of these and is the only FDA-approved medication for bulimia nervosa. Sertraline is the only other SSRI that has been shown to be effective, as demonstrated in a small, randomized controlled trial. In the absence of therapists qualified to treat bulimia nervosa with CBT, fluoxetine is recommended as an initial treatment [I]. Dosages of SSRIs higher than those used for depression (e.g., fluoxetine 60 mg/day) are more effective in treating bulimic symptoms [I]. Evidence from a small open trial suggests fluoxetine may be useful for adolescents with bulimia [II].

      Antidepressants may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms or for patients who have not benefited from or had only a suboptimal response to appropriate psychosocial therapy [I]. Tricyclic antidepressants and MAOIs have been rarely used with bulimic patients and are not recommended as initial treatments [I]. Several different antidepressants may have to be tried sequentially to identify the specific medication with the optimum effect [I].

      Clinicians should attend to the black box warnings relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families if such medications are to be prescribed [I].

      Small controlled trials have demonstrated the efficacy of the anticonvulsant medication topiramate, but because adverse reactions to this medication are common, it should be used only when other medications have proven ineffective [III]. Also, because patients tend to lose weight on topiramate, its use is problematic for normal or underweight individuals [III].

      Two drugs that are used for mood stabilization, lithium and valproic acid, are both prone to induce weight gain in patients [I] and may be less acceptable to patients who are weight preoccupied. However, lithium is not recommended for patients with bulimia nervosa because it is ineffective [I]. In patients with co-occurring bulimia nervosa and bipolar disorder, treatment with lithium is more likely to be associated with toxicity [I].

    1. Maintenance Phase

      Limited evidence supports the use of fluoxetine for relapse prevention [II], but substantial rates of relapse occur even with treatment. In the absence of adequate data, most clinicians recommend continuing antidepressant therapy for a minimum of 9 months and probably for a year in most patients with bulimia nervosa [II]. Case reports indicate that methylphenidate may be helpful for bulimia nervosa patients with concurrent Attention Deficit - Hyperactivity Disorder (ADHD) [III], but it should be used only for patients who have a very clear diagnosis of ADHD [I].

    1. Combining Psychosocial Interventions and Medications

      In some research, the combination of antidepressant therapy and CBT results in the highest remission rates; therefore, this combination is recommended initially when qualified CBT therapists are available [II]. In addition, when CBT alone does not result in a substantial reduction in symptoms after 10 sessions, it is recommended that fluoxetine be added [II].

    1. Other Treatments

      Bright light therapy has been shown to reduce binge frequency in several controlled trials and may be used as an adjunct when CBT and antidepressant therapy have not been effective in reducing bingeing symptoms [III].


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Self-Help Resources For Bulimia Nervosa

Monitoring Your Progress

NOTE: When each of the following presentations finish; you must exit by manually closing its window in order to return to this webpage.

The Healthy Social Behavior Scale lists social behaviors that research has found to be associated with healthy social relationships. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

The Mental Health Scale lists behaviors and symptoms that research has found to be associated with mental health (or disorder). You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

The Life Satisfaction Scale lists the survey questions often used to measure overall satisfaction with life. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

Life Satisfaction Scale (5-Minute Video)

The "Big 6" Dimensions of Mental Health

Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders.

This website uses these 5 major dimensions of human behavior (i.e., Agreeableness, Conscientiousness, Openness/Intellect, Extraversion/Sociability, and Emotional Stability) to describe all mental disorders. This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.

The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].

Desiderata (5-Minute Video)

The following "Morning Meditation" allows you to plan your day using these "Big 6" dimensions of mental health.

The following "Evening Meditation" allows you to review your progress on these "Big 6" dimensions of mental health.

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    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)

  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Economist in grim battle against deceptive scholarship

  • List of Predatory Journals and Publishers

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? Many medical research findings are statistically significant (with a p-value <0.05), but they are not clinically significant because the difference between the experimental and control groups is too small to be clinically relevant.

      For example, the effect of a new drug may be found to be 2% better than placebo. Statistically (if the sample size was large enough) this 2% difference could be statistically significant (with a p-value <0.05). However, clinicians would say that this 2% difference is not clinically significant (i.e., that it was too small to really make any difference).

      Statistically, the best way to test for clinical significance is to test for effect size (i.e., the size of the difference between two groups rather than confounding this with statistical probability).

      When the outcome of interest is a dichotomous variable, the commonly used measures of effect size include the odds ratio (OR), the relative risk (RR), and the risk difference (RD).

      When the outcome is a continuous variable, then the effect size is commonly represented as either the mean difference (MD) or the standardised mean difference (SMD) .

      The MD is the difference in the means of the treatment group and the control group, while the SMD is the MD divided by the standard deviation (SD), derived from either or both of the groups. Depending on how this SD is calculated, the SMD has several versions such, as Cohen's d, Glass's Δ, and Hedges' g.

        Clinical Significance: With Standard Mean Difference, the general rule of thumb is that a score of 0 to 0.25 indicates small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate to large benefit, and above 1.0 a huge benefit. It is a convention that a SMD of 0.5 or larger is a standard threshold for clinically meaningful benefit.

      The statistical summary should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention).

      In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size ( n ), mean ( M ) and standard deviation ( SD ) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean ( M ) is defined as "the sum ( Sum ) of the values of each observation divided by the total number ( n ) of observations". So: M = Sum / n . Thus: ( Sum ) = ( M ) multiplied by ( n ). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate ( M ) multiplied by ( n ). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean ( M ) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value , and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes

Research Topics

Bulimia Nervosa - Core Clinical Journals

Bulimia Nervosa - All Journals

Bulimia Nervosa - Review Articles - Core Clinical Journals

Bulimia Nervosa - Review Articles - All Journals

Bulimia Nervosa - Treatment - Core Clinical Journals

Bulimia Nervosa - Treatment - All Journals

Cochrane Review (The best evidence-based, standardized reviews available)

Strong evidence of effectiveness:
  • Antidepressants compared with placebo for bulimia nervosa (2009) (Currently the review includes 19 trials comparing antidepressants with placebo: 6 trials with TCAs (imipramine, desipramine and amitriptyline), 5 with SSRIs (fluoxetine), 5 with MAOIs (phenelzine, isocarboxazid, moclobemide and brofaromine) and 3 with other classes of drugs (mianserin, trazodone and bupropion). Similar results were obtained in terms of efficacy for these different groups of drugs. The pooled RR for remission of binge episodes was 0.87 (95% CI 0.81-0.93; p<0.001) favouring drugs. The NNT for a mean treatment duration of 8 weeks, taking the non-remission rate in the placebo controls of 92% as a measure of the baseline risk was 9 (95% CI 6 - 16). The RR for clinical improvement, defined as a reduction of 50% or more in binge episodes was 0.63 (95% CI 0.55-0.74) and the NNT for a mean treatment duration of 9 weeks was 4 (95% CI 3 - 6), with a non-improvement rate of 67% in the placebo group. Patients treated with antidepressants were more likely to interrupt prematurely the treatment due to adverse events. Patients treated with TCAs dropped out due to any cause more frequently that patients treated with placebo. The opposite was found for those treated with fluoxetine, suggesting it may be a more acceptable treatment. CONCLUSION: The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared to placebo, with an overall greater remission rate but a higher rate of dropouts. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.)
  • Antidepressants and psychological treatments, alone or combined, for bulimia nervosa (2010) (Psychotherapeutic approaches, mainly cognitive behavior therapy, and antidepressant medication are the two treatment modalities that have received most support in controlled outcome studies of bulimia nervosa. This review found that combination treatments were superior to monotherapy with psychotherapy or antidepressants. This was the only statistically significant difference between treatments. Antidepressant vs. psychotherapy comparisons showed remission rates were 20% for single antidepressants compared to 39% for single psychotherapy. Antidepressant vs. combination treatment comparisons showed remission rates of 42% for combination treatments versus 23% for antidepressants. Psychotherapy vs. combination treatment comparisons showed showed a 36% pooled remission rate for psychological approaches compared to 49% for the combination. Dropout rates were higher for antidepressants than for psychotherapy. For combination treatment, the Number Needed to Treat (NNT) for a mean treatment duration of 15 weeks was 8, and the Number Needed To Harm (NNH) was 7.)
Some evidence of effectiveness:
  • Psychological treatments for people with bulimia nervosa and binging (2009) (Bulimia nervosa (BN) is an eating disorder in which people binge on food and then try to make up for this by extreme measures such as making themselves sick, taking laxatives or starving themselves. We reviewed studies of psychotherapies, including a specific form of psychotherapy called cognitive behavioural therapy (CBT-BN). We compared psychotherapy to control groups who got no treatment (e.g. people on waiting lists) and the specific CBT-BN with other types of psychotherapy. We found that psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders; however psychotherapy can reduce the frequency of binge eating and purging. We found that CBT was better than other therapies, and better than no treatment, at reducing binge eating. Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.)
  • Self-help and guided self-help for eating disorders (2009) (This review aimed to evaluate pure self-help (PSH) and guided self-help (GSH) interventions for eating disorders for all ages and genders, compared to psychological, pharmacological or control treatments and waiting list. Fifteen trials were identified, all focused on bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS), using manual-based self-help. At end of treatment, PSH/GSH did not significantly differ from waiting list in abstinence from bingeing (RR 0.72, 95% CI 0.47 to 1.09), or purging (RR 0.86, 95% CI 0.68 to 1.08), although these treatments produced greater improvement on other eating disorder symptoms, psychiatric symptomatology and interpersonal functioning but not depression.)

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Normal Distribution Of Human Attributes

Regression to the Mean (Or Why Scientific Experiments Require A Control Group)

The "Big 6" Dimensions of Mental Health

Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Five Factor Model of Personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.)

The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].

Which "Big 6" Dimensions of Mental Health Are Impaired in Bulimia Nervosa?

Being kind and honest.
Being unkind or dishonest.
Being diligent and self-disciplined.
Being distractible, impulsive, or undisciplined.
Showing good creativity, problem-solving, and learning ability
Impaired Intellect
Showing decreased creativity, problem-solving, or learning ability.
Being gregarious, assertive and enthusiastic.
Being detached, unassertive, and unenthusiastic.
Emotional Stability
Being emotionally stable and calm.
Emotional Distress
Being emotionally unstable/distressed.
      Emotional Distress
Physical Health
Being physically fit and healthy.
Physical Symptoms
Being physically unfit or ill.
      Physical Symptoms

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are characteristic of this disorder are highlighted with this pink background color.


Description: Emotional Stability is synonymous with stability and calm. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. Individuals with high Emotional Stability are relatively tough, brave, and insensitive to physical pain, feel little worry even in stressful situations, and have little need to share their concerns with others. High Emotional Stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, rarely angry, rarely depressed or moody, rarely anxious or embarrassed.
  • From Between facets and domains: 10 aspects of the Big Five
    • Stability:
      • Rarely get irritated
      • Keep my emotions under control
      • Rarely lose my composure
      • Am not easily annoyed
    • Calm:
      • Relaxed, handle stress well
      • Feel comfortable with myself
      • Am not embarrassed easily
      • Seldom feel blue
      • Rarely feel depressed
  • From International Personality Item Pool:
    • Remain calm under pressure
    • Rarely get irritated
    • Feel comfortable with myself
    • Relaxed most of the time
    • Am not embarrassed easily
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
EMOTIONAL DISTRESS (Impaired Stability)
Description: Emotional Distress is synonymous with emotional volatility and negative emotion. Individuals with high emotional volatility are easily upset or angered. They often are very moody and emotionally labile. Individuals that have high negative emotion exhibit over-sensitivity to threat or stress. They exhibit excessive fear, anxiety, depression, or irritability.
ICD-11 Description: The core feature of the Emotional Distress (or Negative Affectivity) trait domain is the tendency to experience a broad range of negative emotions. Common manifestations of Emotional Distress include: experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation; emotional lability and poor emotion regulation; negativistic attitudes; low self-esteem and self-confidence; and mistrustfulness.
Descriptors: Easily upset, angry, depressed, moody, anxious, embarrassed.
  • From Between facets and domains: 10 aspects of the Big Five
    • Emotional Instability:
      • Get angry or upset easily
      • Change my mood a lot
      • Am a person whose moods go up and down easily
      • Get easily agitated
      • Can be stirred up easily
    • Negative Emotion:
      • Worry a lot
      • Get nervous easily
      • Am filled with doubts about things
      • Feel threatened easily
      • Am easily discouraged
      • Become overwhelmed by events
      • Am afraid of many things
  • From International Personality Item Pool:
    • Panic easily
    • Get angry easily
    • Often feel blue
    • Worry about things
    • Am easily intimidated
Evolution: All animals have evolved a "fight or flight" response to threat to ensure their survival. Mammals went one step further and evolved a "fight, flight, or freeze" response to threat. In humans, this mammalian "freeze" response to threat involves inhibition of behavior in response to threat, punishment, and emotional distress. This threat response of "freezing", shutting down or passively avoiding is commonly seen in human anxiety or depression (e.g., freezing with fear or being immobilized by indecision, worry or depression).
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Screening Questions:
  • "I worry about almost everything."
  • "I get emotional easily, often for very little reason."
  • "I fear being alone in life more than anything else."
  • "I get stuck on one way of doing things, even when it’s clear it won’t work."
  • "I get irritated easily by all sorts of things."
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Emotional Distress or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and emotional distress.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
("Emotional Stability vs. Emotional Distress" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five) [More Information]
*MRI Research:
Testing predictions from personality neuroscience. Brain structure and the big five.

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