Study: Mental health providers often miss bulimia diagnosis

When presented with a vignette describing the behaviors and characteristics of a patient with disordered eating, only a quarter of mental health providers who participated in a new study were able to correctly diagnose bulimia nervosa.

The findings from researchers at the University of Florida College of Public Health and Health Professions, part of UF Health, appear in the journal Eating Disorders.

Two common, yet less-recognized, patient factors may have led to the misdiagnoses, said Dakota Leget, a doctoral student in the college's Ph.D. program in clinical and health psychology, who conducted the study with her mentor, Rebecca Pearl, Ph.D., an associate professor in the Department of Clinical and Health Psychology. The providers who participated in the study reviewed vignettes about a fictitious patient who was described as either having healthy weight or obesity and who used excessive exercise to compensate for overeating.

Many patients with bulimia have average or higher body weight, yet misconceptions persist about the "typical" patient with bulimia, Leget said.

"Unfortunately, we have stereotypes that someone with an eating disorder will look 'very lean' or 'sickly,' but we know that's not the case for a lot of eating disorders," she said.

The study findings also suggest that providers may not associate excessive exercise with bulimia, despite the fact that it is listed in the Diagnostic and Statistical Manual of Mental Disorders as one of multiple compensatory strategies used by people with bulimia.

I think my biggest takeaway is that excessive exercise may not be on mental health providers' radar and may be overlooked when patients are presenting for care."  

Dakota Leget, doctoral student, University of Florida

For the study, the researchers recruited a nationwide sample of more than 200 mental health providers to read two patient vignettes and then select a diagnosis and recommended number of treatment sessions from a dropdown list of options. The vignettes described fictitious patients who met full diagnostic criteria for their respective disorders, according to the Diagnostic and Statistical Manual of Mental Disorders.

Three-quarters of participants correctly diagnosed major depressive disorder in the first patient vignette, which served as a control.

Participants were randomly assigned to receive one of two versions of the second vignette. In one version, the patient was described as having a healthy weight; in the second, the patient was described as having obesity. The other patient details were the same for both versions. The patient in the vignette reported she followed a strict diet a few days a week and engaged in a cycle of binge eating accompanied by excessive exercise. The vignette also described the patient's thoughts and feelings about her appearance and how they affected her activities and relationships.

Only 27% of providers correctly diagnosed the patient as having bulimia nervosa, and 38% of providers incorrectly diagnosed the patient with binge eating disorder.

Correctly distinguishing between bulimia, binge eating or any other eating disorder is critical, the authors say, not only to ensure patients receive the right treatment, but also to appropriately monitor for other health effects, such as dangerously low sodium levels caused by excessive exercise.

"If you are treating the wrong eating disorder, you might not be using the best evidence-based strategy," Leget said.

The findings also point to the need for more continuing education on eating disorders for mental health providers who may not have specialized training, Leget said.

"Many people with eating disorders will probably be seen in outpatient settings and they may not be seen by someone with expertise in this area," Leget said. "Early detection and treatment are crucial. If the community provider is able to detect an eating disorder they can treat that person or guide them to someone with the appropriate expertise so the patient gets the treatment they need sooner rather than later."