Bulimia nervosa

Last updated: March 14, 2023

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Bulimia nervosa is an eating disorder characterized by recurrent binge eating episodes, inappropriate weight compensatory behaviors, and sense of self-worth disproportionately impacted by body weight and/or shape. Causes are multifactorial and similar to those of anorexia nervosa (e.g., genetic factors, psychiatric disorders, psychosocial factors); bulimia nervosa is associated with obesity. It is important to assess for malnutrition severity in affected individuals, regardless of body weight or body mass index (BMI). The diagnosis is confirmed if individuals fulfill all of the DSM-5 diagnostic criteria for bulimia nervosa. Individuals should be evaluated for associated complications (e.g., electrolyte abnormalities) and underlying conditions that may affect weight or cause a change in eating behaviors (e.g., thyroid disorder). Outpatient management is preferred, but hospitalization is indicated if red flags in eating disorders are present. All individuals should be referred for psychotherapy and nutritional management. Pharmacotherapy with fluoxetine may be considered as adjunctive therapy to help decrease binge eating and compensatory behaviors; other SSRIs may also be used to manage comorbid psychiatric conditions (e.g., depression).

  • Prevalence
    • Women: 0.3%–1%
    • Men: 0.1%
  • Peak age: 20–24 years of age
  • Sex: > (> 90% of affected individuals are young women)

Epidemiological data refers to the US, unless otherwise specified.

Associated features of bulimia nervosa [1]
Clinical features
Central nervous system
Cardiovascular symptoms
Gastrointestinal tract
Menstrual irregularities

Recurrent purging can lead to severe complications such as esophageal tears, cardiac arrhythmias, and seizures. [1]

Bulimia nervosa is associated with an increased risk of suicide. [1]

General principles [1][4][5][6][7]

DSM-5 diagnostic criteria [1][5]

DSM-5 diagnostic criteria for bulimia nervosa [1]
  • Recurrent inappropriate weight compensatory behaviors to counteract weight gain, e.g.:
    • Self-induced vomiting after binge eating (most common)
    • Laxative misuse
    • Transient starvation periods
    • Excessive exercise
    • Prescription drug misuse
  • Sense of self-worth disproportionately influenced by the perception of one's weight and/or body shape
All criteria must be fulfilled.

Binge eating episodes can occur during periods of stress or boredom, or after an attempt to lower body weight through dietary restriction. [1]

Severity (according to DSM-5) [1][8]

Based on the number of episodes of inappropriate weight compensatory behaviors per week.

  • Mild: 1–3 episodes/week
  • Moderate: 4–7 episodes/week
  • Severe: 8–13 episodes/week
  • Extreme: ≥ 14 episodes/week

Laboratory studies [1]

General principles [5][6][7]

Nutritional management [5][6][7]

Psychotherapy [5][6][7]

First-line therapy for bulimia nervosa

Adolescents and young adults


If a guided self-help approach is used, a lack of improvement within 4 weeks of initiation should prompt referral to an eating disorder specialist. [6]

Pharmacotherapy [5][6][7]

Indications [6][7]

  • Adults: may consider either of the following [6]
    • Initial combination treatment of pharmacotherapy and psychotherapy
    • Addition of pharmacotherapy after a 6-week trial of psychotherapy alone (if there is minimal or no response)
  • Adolescents: less evidence for use, but may be considered (off-label)
  • All patients: management of co-occurring psychiatric conditions (e.g., depression, obsessive compulsive disorder)

Pharmacotherapy should be used only as an adjunct to psychotherapy in the management of bulimia nervosa. [5][6][7]

Agents [6]

The antidepressant bupropion lowers the seizure threshold and is contraindicated in individuals with a history of anorexia nervosa, bulimia nervosa, or purging behaviors. [6]

There is an increased risk of QTc prolongation with high doses of citalopram and escitalopram. [7]

If patients do not experience symptom improvement with pharmacotherapy, determine whether the medication is being taken shortly before episodes of vomiting. [6]

See “Complications of eating disorders.”

We list the most important complications. The selection is not exhaustive.

Bulimia nervosa can transition to anorexia nervosa and vice versa. [1]

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association ; 2013
  2. Eating Disorders Among Adults - Bulimia Nervosa. https://www.nimh.nih.gov/health/statistics/prevalence/eating-disorders-among-adults-bulimia-nervosa.shtml. Updated: June 6, 2017. Accessed: June 6, 2017.
  3. National Institute of Mental Health: Eating Disorders. https://web.archive.org/web/20230115042131/https://www.nimh.nih.gov/health/statistics/eating-disorders. Updated: November 1, 2017. Accessed: October 9, 2020.
  4. Davidson KW, Barry MJ, et al. Screening for Eating Disorders in Adolescents and Adults. JAMA. 2022; 327 (11): p.1061-1067. doi: 10.1001/jama.2022.1806 . | Open in Read by QxMD
  5. Hornberger LL et al. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2021; 147 (1). doi: 10.1542/peds.2020-040279 . | Open in Read by QxMD
  6. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. undefined. 2022 . doi: 10.1176/appi.books.9780890424865 . | Open in Read by QxMD
  7. Klein DA, Sylvester JE, Schvey NA. Eating Disorders in Primary Care: Diagnosis and Management. Am Fam Physician. 2021; 103 (1): p.22-32.
  8. Harrington BC, Jimerson M, Haxton C, Jimerson DC. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician. 2015; 91 (1): p.46-52.
  9. Arcelus J et al. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies.. Arch Gen Psychiatry. 2011; 68 (7): p.724-31. doi: 10.1001/archgenpsychiatry.2011.74 . | Open in Read by QxMD
  10. Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of Anxiety Disorders With Anorexia and Bulimia Nervosa. Am J Psychiatry. 2004; 161 (12): p.2215-2221. doi: 10.1176/appi.ajp.161.12.2215 . | Open in Read by QxMD

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