Bulimia nervosa

Last reviewed: 22 Aug 2023
Last updated: 09 Jun 2023



History and exam

Key diagnostic factors

  • recurrent episodes of binge eating
  • recurrent inappropriate compensatory behavior
  • eating disturbance not exclusively during periods of anorexia nervosa
  • depression and low self-esteem
  • concern about weight and body shape
  • dental erosion
  • parotid hypertrophy
  • Russell sign
  • arrhythmia
More key diagnostic factors

Other diagnostic factors

  • age 20-35 years
  • menstrual irregularity
  • drug-seeking behavior
  • deliberate misuse of insulin
  • self-injurious behavior
  • gastrointestinal symptoms
  • history of dieting
  • marked fluctuations in weight
  • shoplifting behavior
  • use of ipecac
  • needle marks on skin
  • vomiting in pregnancy
Other diagnostic factors

Risk factors

  • female sex
  • personality disorder
  • body image dissatisfaction
  • history of sexual abuse
  • impulsivity
  • family history of alcoholism
  • family history of depression
  • family history of eating disorder
  • childhood overweight or obesity
  • exposure to media pressure
  • early onset of puberty
  • urbanization
  • family history of obesity
  • participation in elite-level sports
More risk factors

Diagnostic investigations

1st investigations to order

  • serum electrolytes
  • serum creatinine
  • serum magnesium
  • urine pregnancy test
  • serum LFTs
  • serum creatine kinase (CK)
  • CBC
  • urinalysis
More 1st investigations to order

Investigations to consider

  • ECG
  • serum ferritin
  • serum B12
  • serum red blood cell folate
  • dual-energy x-ray absorptiometry scan for bone density
More investigations to consider

Treatment algorithm


nonpregnant adults

children and adolescents




Debra L. Safer, MD

Associate Professor

Co-Director of Stanford Eating and Weight Disorders Program

Stanford University School of Medicine

Department of Psychiatry & Behavioral Sciences




DLS is an author of a reference cited in this topic, and receives royalties from Guilford Press for books on adapting dialectical behavior therapy for eating disorders.


Dr Debra L. Safer would like to gratefully acknowledge Dr David C.W. Lau and Dr C. Laird Birmingham, the previous contributors to this topic.


DCWL declares that he has no competing interests. CLB is an author of several references cited in this topic.

Peer reviewers

Mimi Israel, MD, FRCPC

Chair of Psychiatry

McGill University




MI declares that she has no competing interests.

Joel Yager, MD


Department of Psychiatry

University of New Mexico School of Medicine




JY is an author of a reference cited in this topic.

  • Bulimia nervosa images
  • Differentials

    • Other specified feeding or eating disorder (OSFED), or unspecified feeding or eating disorder (UFED)
    • Anorexia nervosa, binge-eating/purging subtype
    • Binge-eating disorder
    More Differentials
  • Guidelines

    • The hospitalized adolescent
    • Practice guideline for the treatment of patients with eating disorders
    More Guidelines
  • Patient leaflets

    Bulimia: what is it?

    Bulimia: what treatments work?

    More Patient leaflets
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