Recurrent binge eating with inappropriate compensatory behaviors; normal or above-normal weight.
Also known as: bulimia, bulimia nervosa
Overview
An eating disorder characterized by recurrent episodes of binge eating accompanied by recurrent inappropriate compensatory behaviors (vomiting, laxatives/diuretics, fasting, excessive exercise) at least once weekly for 3 months, with self-evaluation unduly influenced by body shape and weight. Patients are typically of normal or above-normal weight.
Epidemiology
Lifetime prevalence ~1-2% in women, ~0.5% in men. Onset typically late adolescence. Frequently comorbid with depression, anxiety, substance use, BPD.
Try two board-style Bulimia Nervosa questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1PsychiatryMedium
A 35-year-old woman with a history of bulimia nervosa in remission for 2 years has a BMI of 38 and asks about pharmacotherapy for weight loss. Which of the following medications is most clearly contraindicated given her history of bulimia nervosa?
ABupropion-naltrexone
BPhentermine-topiramate
COrlistat
DSemaglutide
ETirzepatide
Reveal answer & full explanation
Correct answer: A — Bupropion-naltrexone
ABupropion-naltrexone✓
BPhentermine-topiramate
COrlistat
DSemaglutide
ETirzepatide
Why bupropion-naltrexone is correct
A current or prior eating disorder (bulimia or anorexia nervosa) is a labeled contraindication to bupropion-naltrexone, so her remitted bulimia makes this the agent that is most clearly contraindicated
The bupropion component lowers the seizure threshold, and eating disorders carry electrolyte disturbances (e.g., from purging) that further raise seizure risk
The contraindication applies to prior disease, not only active disease, so 2 years of remission does not remove it
Why the others are wrong
Phentermine-topiramate — eating disorder is not a labeled contraindication, and topiramate actually reduces binge-eating behavior; picking it is buzzword-matching "weight-loss stimulant" rather than the specific eating-disorder contraindication
Orlistat — has no eating-disorder contraindication; the trap is premature closure on a theoretical concern about misuse in active purging, but this patient is in remission and the drug carries no formal contraindication
Semaglutide — a glucagon-like peptide-1 (GLP-1) agonist with no eating-disorder contraindication and generally considered a safer option here; chosen if the learner assumes any weight-loss drug is risky in this history
Tirzepatide — a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist and one of the most potent appetite-suppressing agents, so it may seem the riskiest choice after an eating disorder, but eating-disorder history is not a labeled contraindication; its labeled contraindications center on a personal or family history of medullary thyroid carcinoma or MEN2
Question 2PsychiatryEasy
A 30-year-old female has recurrent episodes of binge eating large amounts of food in under 2 hours with loss of control, followed by self-induced vomiting. She is normal weight. Labs show hypokalemia and metabolic alkalosis. Physical exam shows bilateral parotid gland enlargement and dental enamel erosion. Which of the following is the most likely diagnosis?
AAnorexia nervosa
BBinge eating disorder
CRumination disorder
DPurging disorder
EBulimia nervosa
Reveal answer & full explanation
Correct answer: E — Bulimia nervosa
AAnorexia nervosa
BBinge eating disorder
CRumination disorder
DPurging disorder
EBulimia nervosa✓
Why Bulimia nervosa is correct
Bulimia nervosa (BN): recurrent binge eating plus compensatory behaviors (purging, laxatives, excessive exercise) plus normal or near-normal weight
Medical complications include hypokalemia with metabolic alkalosis from vomiting, dental erosion, parotid hypertrophy, and Russell sign (calluses on dorsum of hand)
Why the others are wrong
Purging disorder — involves purging without binge eating episodes; this patient has clear binge-eating episodes with loss of control
Binge eating disorder — involves recurrent binge eating without compensatory behaviors; this patient self-induces vomiting
Anorexia nervosa — characterized by low body weight and restrictive eating; this patient is normal weight
Rumination disorder — also a DSM-5 feeding and eating disorder with repeated return of swallowed food, but it is effortless regurgitation that is re-chewed, re-swallowed, or spit out, without binge episodes or deliberate self-induced vomiting
Additional high-yield points
Treatment: enhanced cognitive behavioral therapy (CBT-E) is most effective with 40-50% remission
Fluoxetine 60 mg is the only FDA-approved medication for BN
Combination CBT plus fluoxetine is superior to either alone
Bupropion (including naltrexone-bupropion) is contraindicated with a current or prior diagnosis of BN because it lowers the seizure threshold, a risk compounded by purging-related electrolyte imbalances
That's 2. Get 7,700+ more.
Unlock the full FirstPassPA bank: 7,700+ board-style questions, flashcards, and an AI tutor that explains every answer. Your 7-day free trial includes everything, and there's no credit card required.
You've read your 2 free diagnosis previews. Create your free account to unlock the full Bulimia Nervosa outline — plus all 514 diagnoses, 7,700+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Family history of eating, mood, or substance use disorders
Impulsivity, emotion dysregulation
Childhood obesity, early dieting, trauma history
Athletic or appearance-focused environments
Pathophysiology
Dysregulated reward and impulse control with serotonergic and dopaminergic alterations; biopsychosocial model emphasizing dietary restraint as a precipitant for binge episodes followed by guilt-driven compensation.
Clinical presentation
Symptoms
Binge: eating an objectively large amount of food in <2 hours with sense of loss of control
Body shape and weight unduly influence self-evaluation
Signs / physical exam
Russell's sign (knuckle calluses)
Parotid and submandibular gland hypertrophy
Dental erosion (lingual surface of upper teeth), caries
Esophagitis, hematemesis, rare Mallory-Weiss tear or Boerhaave
Electrolyte disturbances: hypokalemia, hypochloremic metabolic alkalosis with vomiting; non-anion gap metabolic acidosis with laxative misuse
Differential diagnosis
Anorexia nervosa binge-purge type — Significantly low weight present
Binge eating disorder — Binges without compensatory behaviors
MDD with binge eating — Episodic eating during mood episodes without compensatory behaviors
Kleine-Levin syndrome — Periodic hypersomnia with hyperphagia, hypersexuality
GI causes of vomiting — Cyclic vomiting syndrome, gastroparesis — no body image disturbance
Purging disorder (OSFED) — Recurrent purging to control weight or shape WITHOUT binge eating
Diagnostic workup
Diagnostic criteria
DSM-5-TR: (A) Recurrent binge eating — large amount + loss of control; (B) Recurrent inappropriate compensatory behaviors; (C) Both occur on average >=1/week for >=3 months; (D) Self-evaluation unduly influenced by body shape/weight; (E) Disturbance does not occur exclusively during anorexia nervosa episodes. Severity by frequency: mild 1-3, moderate 4-7, severe 8-13, extreme >=14 episodes/week.
Bupropion, including naltrexone-bupropion (Contrave), is CONTRAINDICATED with a current OR prior diagnosis of bulimia or anorexia nervosa (seizure risk) — choose fluoxetine for comorbid depression.
Fluoxetine at 60 mg/day (higher than depression dose) is the FDA-approved dose for bulimia.
Most patients are at normal weight — absence of cachexia does not exclude an eating disorder.
Address dietary restriction in treatment — restriction perpetuates the binge cycle.
Screen with SCOFF questionnaire (>=2 positive raises concern).
References
APA 2023 — American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, 4th ed. (2023)
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.