Bulimia Nervosa
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.
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Risk factors
- Female sex, adolescence/young adulthood
- 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
- Compensatory behaviors: self-induced vomiting (most common), laxative or diuretic misuse, fasting, excessive exercise
- Both occur on average >=1/week for >=3 months
- 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
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.
Labs
- CMP (K, Cl, HCO3, Mg, phosphate), CBC, amylase, lipase
- ECG if electrolyte abnormality (QT prolongation, U waves with hypokalemia)
- Pregnancy test
- Urine sodium/chloride to detect surreptitious vomiting (low Cl)
Imaging
- Not routinely indicated; CXR if subcutaneous emphysema or chest pain (Boerhaave)
Diagnostic algorithm
| Severity | Episodes/week |
|---|---|
| Mild | 1-3 |
| Moderate | 4-7 |
| Severe | 8-13 |
| Extreme | >=14 |
Treatment
First-line
- Cognitive behavioral therapy for eating disorders (CBT-ED) — strongest evidence base
- Interpersonal therapy (IPT) — alternative
- Family-based treatment for adolescents
- Fluoxetine 60 mg/day — FDA-approved; reduces binge/purge frequency
- Nutritional counseling — structured eating to interrupt restriction-binge cycle
Second-line / adjunct
- Other SSRIs at higher doses if fluoxetine not tolerated
- Topiramate — weight loss side effect can be problematic; teratogenic
- AVOID bupropion (lowers seizure threshold; contraindicated in active bulimia)
- Treat electrolyte abnormalities; dental care
- Partial hospitalization or residential for severe disease
Complications
- Electrolyte: hypokalemia (arrhythmias), hypochloremic metabolic alkalosis, hypomagnesemia
- Dental erosion, caries, parotid hypertrophy
- Esophagitis, Mallory-Weiss tear, rare esophageal rupture
- Cardiac arrhythmias (especially with ipecac or severe electrolyte derangement)
- Ipecac-induced cardiomyopathy
- Substance use, self-harm, suicidality (elevated suicide risk)
- Menstrual irregularity, infertility
PANCE pearls
- Bupropion is CONTRAINDICATED in active bulimia and anorexia (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)
- NICE NG69 — NICE Guideline 69: Eating disorders: recognition and treatment
- Fairburn CBT-E — Fairburn CG. Cognitive Behavior Therapy and Eating Disorders (2008)
- DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
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