# Defining Recovery and Relapse in Bulimia Nervosa: A Systematic Review of the Literature

## TL;DR

This paper reviews how recovery and relapse in bulimia nervosa are defined in research, finding inconsistent standards that hinder accurate comparisons and assessments.

## Contribution

The study systematically identifies and categorizes definitions of recovery and relapse in bulimia nervosa to propose a more standardized approach.

## Key findings

- Recovery is most often defined using diagnostic or behavioral criteria, such as absence of binge eating and compensatory behaviors.
- Relapse is commonly defined by the return of behavioral symptoms or meeting DSM diagnostic criteria after remission.
- Fewer studies incorporate medical or psychological criteria into definitions of recovery and relapse.

## Abstract

Despite advances in understanding bulimia nervosa (BN), standardized definitions of outcome stages remain lacking. This review aims to synthesise definitions of recovery and relapse in BN to improve its assessment and comparability across study outcomes.

A systematic review was conducted using PRISMA guidelines. PubMed and PsycINFO were searched (October 2024) combining keywords ‘recovery’, ‘remission’ or ‘relapse’ with ‘bulimia nervosa’.

N = 76 studies were included. Recovery was most commonly defined using diagnostic (n = 30, 53%; For example, a Psychiatric Status Rating score ≤ 2 and absence of a DSM‐based diagnosis) or behavioural criteria (n = 28, 49%; typically binge eating and compensatory behaviours assessed with the Eating Disorder Examination interview/questionnaire; EDE/EDE‐Q). Fewer studies considered medical/physical (n = 17, 30%; That is, Body Mass Index ≥ 18.5) or psychological criteria (n = 10, 18%; For example, EDE/EDE‐Q global or all subscales score within 1SD of community norms). N = 11 (14%) addressed partial recovery as a period of symptomatic improvement with residual symptoms. Relapse was defined using behavioural criteria (n = 18, 25%; That is, re‐emergence of binge eating and compensatory behaviours) or meeting DSM‐based diagnostic criteria after remission (n = 10, 14%).

Adopting multidimensional definitions of recovery and relapse, incorporating the most endorsed behavioural, diagnostic, medical/physical, and psychological criteria, may increase diagnostic accuracy, facilitate assessment and outcomes comparability.

There is a lack of standardized definitions in the literature for recovery and relapse in bulimia nervosa, making it difficult to compare outcomes across studies and assess treatment outcomes accurately.Recovery from bulimia nervosa in the literature was most commonly defined by diagnostic criteria (a Psychiatric Status Rating score ≤ 2 or absence of a DSM‐based diagnosis) or the absence of core behavioural symptoms, such as binge eating and compensatory behaviours.Partial recovery from bulimia nervosa, which precedes full recovery, was most commonly defined as a period of symptomatic improvement with the persistence of residual symptoms.Relapse from bulimia nervosa was most commonly defined as the return of behavioural symptoms (i.e., binge eating and compensatory behaviours) or a meeting again the threshold for a DSM‐based diagnosis after a period of remission. This underscores the importance of targeted relapse prevention during this vulnerable period.

There is a lack of standardized definitions in the literature for recovery and relapse in bulimia nervosa, making it difficult to compare outcomes across studies and assess treatment outcomes accurately.

Recovery from bulimia nervosa in the literature was most commonly defined by diagnostic criteria (a Psychiatric Status Rating score ≤ 2 or absence of a DSM‐based diagnosis) or the absence of core behavioural symptoms, such as binge eating and compensatory behaviours.

Partial recovery from bulimia nervosa, which precedes full recovery, was most commonly defined as a period of symptomatic improvement with the persistence of residual symptoms.

Relapse from bulimia nervosa was most commonly defined as the return of behavioural symptoms (i.e., binge eating and compensatory behaviours) or a meeting again the threshold for a DSM‐based diagnosis after a period of remission. This underscores the importance of targeted relapse prevention during this vulnerable period.