Bulimia nervosa is an eating disorder, characterized by severe preoccupation about weight and body shape. Includes recurrent episodes of binge eating with compensatory mechanisms, such as self-induced vomiting to prevent weight gain.
Most common in women in their 20s and 30s.
Patients usually appear physically normal, although they may have low self-esteem and depressive thoughts, as well as lack of confidence.
Parotid hypertrophy and erosion of the teeth are the most common physical signs and may prompt diagnosis.
Cognitive behavioral therapy (CBT) is considered optimal primary treatment for bulimia, but it may not always be available.
Selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be used adjunctively to CBT, or as an alternative when CBT is not available.
Treatment of comorbid psychiatric disorders, such as major depressive disorder and obsessive-compulsive disorder, is necessary to optimize the chance of recovery from bulimia nervosa. SSRIs are effective in additional treatment of comorbid psychiatric disease.
Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating, followed by behaviors aimed at compensating for the binge. Binge-eating episodes are characterized by eating an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances, and a sense of lack of control over eating during the episode. Recurrent inappropriate compensatory behaviors occur in order to prevent weight gain. These behaviors include self-induced vomiting; fasting; excessive exercise; and misuse of laxatives, diuretics, enemas, or other medication. Binge-eating episodes typically occur, on average, at least weekly for 3 months.
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
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
- female sex
- personality disorder
- body image dissatisfaction
- history of sexual abuse
- 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
- family history of obesity
1st investigations to order
- serum electrolytes
- serum creatinine
- serum magnesium
- urine pregnancy test
- serum LFTs
- serum creatine kinase (CK)
Investigations to consider
- serum ferritin
- serum B12
- serum red blood cell folate
- dual-energy x-ray absorptiometry scan for bone density
children and adolescents
Debra L. Safer, MD
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.
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.
Mimi Israel, MD, FRCPC
Chair of Psychiatry
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.
- Other specified feeding or eating disorder (OSFED), or unspecified feeding or eating disorder (UFED)
- Anorexia nervosa, binge-eating/purging subtype
- Binge-eating disorder
- Practice guideline for the treatment of patients with eating disorders
- Eating disorders: a national clinical guideline
Bulimia: what is it?
Bulimia: what treatments work?More Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer