Bulimia Nervosa

Updated: Apr 14, 2023
  • Author: Donald M Hilty, MD, MBA; Chief Editor: David Bienenfeld, MD  more...
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Practice Essentials

Bulimia nervosa (BN) is an eating disorder with 5 key characteristics as noted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). [1]

  1. Recurrent episodes of binge eating. Eating more than the average person in a 2-hour period, accompanied by a sense of loss of control.
  2. Repetitive inappropriate compensatory behaviors to avoid weight gain such as excessive exercise, fasting, laxative use, and diuretic use.
  3. This eating behavior occurs at least once a week for a period of 3 months.
  4. Body shape and weight influence self-evaluation.
  5. This does not occur specifically with episodes of anorexia nervosa.

Signs and symptoms

Patients with BN may experience the following symptoms: [2, 3, 4]

  • General - Dizziness, lightheadedness, palpitations (due to dehydration, orthostatic hypotension, possibly hypokalemia), dry skin

  • Gastrointestinal symptoms - Pharyngeal irritation, abdominal pain (more common among persons who self-induce vomiting), blood in vomitus (from esophageal irritation; more rarely, from actual tears, which may be fatal), difficulty swallowing, bloating, flatulence, constipation, obstipation, and gastroesophageal reflux disease (GERD) [5]

  • Reproductive symptoms - Amenorrhea occurs in up to 50% of women with BN; significant proportion of remaining patients have irregular periods; many more will have menstrual irregularity and scanty periods

  • Uncommon symptoms, or in most severe cases

    • Water and electrolytes - Dehydration, hypokalemia, hypochloremia, metabolic alkalosis

    • Cardiac - Edema; EKG changes such as QT prolongation, increased PR interval, increased P wave amplitude, widened QRS, depressed ST segment

    • Gastrointestinal - Gastric dilation, Barrett's esophagus [5]

    • Pulmonary symptoms - aspiration pneumonitis (uncommon), pneumomediastinum (rare)

Physical findings may include the following:

  • Bilateral parotid enlargement (see the image below)

    Parotid hypertrophy. Reprinted with permission fro Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.
  • Dental damage (see the image below)

    Dental caries. Reprinted with permission from Wolc Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.
  • Russell sign (see the image below)

    Russell sign. Reprinted with permission from Glori Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.
  • Cutaneous manifestations, including sudden, diffuse hair loss, acne, dry skin, nail dystrophy, and scarring resulting from cutting, burning, and other self-induced trauma

  • Bradycardia or tachycardia, hypothermia, and hypotension (often associated with dehydration)

  • Edema

  • Clinical obesity; morbid obesity is rare

See Clinical Presentation for more detail.


Laboratory studies

Lab studies that may be used for diagnosis include:

  • Comprehensive blood chemistry panel

  • Complete blood count (CBC)

  • Urinalysis

  • Urine toxicology screen

  • Pregnancy test

  • Amylase level


Because of the potential for arrhythmias and cardiomyopathy as possible complications of BN, an electrocardiogram (ECG) should be performed in patients who are very thin, complaining of palpitations, or have other signs or symptoms of cardiovascular concern. [6]


Because of the potential for osteoporosis, a dual-energy radiographic absorptiometry (DEXA) scan may be useful, particularly for patients with irregular menses, who have mood disorders, and/or who smoke cigarettes.

See Workup for more detail.


Imaging studies are not routinely indicated or ordered for uncomplicated or typical cases of BN. Nonetheless, there has been growing interest in the use of neuroimaging techniques to explore the structural and functional brain changes that take place in those with eating disorders, mostly focusing on patients with anorexia nervosa, but now starting in BN.

See Workup for more detail.


A meta-analysis of 45 randomized controlled trials (RCTs) assessed the prevalence of patients who abstain from binge eating and/or purging following all psychological treatments for BN, and moderated impact by the type of 78 psychotherapies delivered and the trial quality. [7] At post-treatment, the total weighted percentage of treatment-completers who achieved abstinence was 35.4% (95% CI = 29.6, 41.7), while the total weighted percentage of abstinence for all randomized patients (intention-to-treat) was 29.9% (95% CI = 25.7, 33.2). Abstinence estimates were highest in trials that used CBT and BT; guided self-help interventions produced the lowest post-treatment abstinence rates. Overall, 60% of patients fail to fully abstain from core BN symptoms even after receiving empirically supported treatments.

Core nonpharmacologic interventions for BN include the following:

  • Cognitive-behavioral therapy (CBT)

  • Cognitive-behavioral therapy enhanced (CBT-E) for patients with more complex cases including comorbidities involving personality

  • Interpersonal psychotherapy (IPT)

  • Nutritional rehabilitation counseling

  • Family therapy

Pharmacologic agents used in the treatment of BN include the following:

  • Fluoxetine (Prozac) - Approved by the FDA for the treatment of BN

  • Other antidepressants - As a group, antidepressants are the mainstay of pharmacotherapy for BN; [8] they may help patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms

  • Mood stabilizers - Topiramate, lithium, and valproic acid have been associated with adverse effects that can make these agents difficult to use in patients with BN; lithium has not been demonstrated to be effective for BN per se

See Treatment for more detail.



Bulimia nervosa (BN) is an eating disorder delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). [1] Among the eating disorders, bulimia nervosa and anorexia nervosa (AN) are far more common in young females, while binge-eating disorder, the most common eating disorder overall, is more common in adults.

BN includes regularly occurring compensatory behaviors that are intended to rid the body of the excess calories consumed during eating binges. BN is distinguished from the recently delineated syndrome of binge-eating disorder, in which no regular or consistent compensatory behavior accompanies the bingeing episodes. Although the DSM-5-TR describes that compensatory behaviors may include purging and/or nonpurging behaviors (see below), in contrast to earlier DSM editions, DSM-5-TR no longer maintains specific purging and nonpurging subtypes. The frequent association of cigarette smoking with BN may at times reflect compensatory behavior, in that nicotine use appears to suppress, whereas smoking cessation provokes, weight gain in some individuals.

In up to 60% of cases, patients with BN report prior histories of AN. In contrast to individuals with uncomplicated binge-eating disorder who tend to be obese, people with BN are more typically of normal weight, although some degree of overlap between nonpurging BN and binge-eating disorder is seen. The natural history of eating disorders is such that individuals may pass through several diagnoses over time, with some meeting criteria for AN, BN, and binge-eating disorder at various points. The development of AN in individuals who initially present with BN is possible, although less common. [9]

Binge eating

BN is characterized by frequent episodes of binge eating associated with emotional distress and a sense of loss of control.

Binge eating: Eating, in a discrete period of time (eg, 2 hours) an amount of food that is significantly larger than is typical for most people during the same defined period. This behavior is associated with a perceived loss of control of eating during this time.

Overeating episode: The consumption of an unusually large amount of food in a defined period, without concomitant perception of loss of control.

Subjective bulimic episode: The consumption of objectively minimal amounts of food in a defined period with a perception of loss of control.

Compensatory behaviors

Compensatory behaviors used by individuals with BN include self-induced vomiting, laxative abuse, excessive exercise generally experienced as being joyless and/or compulsive, episodes of fasting or strict dieting, diuretic abuse, use of appetite suppressants, failure to use insulin in those with type I diabetes, and/or the use of medications intended to speed up metabolism (eg, thyroid hormone, stimulants). DSM-5-TR diagnostic criteria require episodes of binge eating that occur at least once weekly for 3 months. Individuals with BN are also dissatisfied with their body shape, weight, or both.


AN and BN are characterized by abnormalities in eating behaviors associated with a fear of weight gain and usually some degree of body image distortion (believing one looks much fatter than is actually the case). These are accompanied by associated abnormalities in mood and in perceptions of hunger and satiety. Disordered eating and weight control efforts can manifest as dietary restriction, binge eating, and/or other compensatory behaviors intended to prevent weight gain, as noted above.

For more information, see Medscape's Eating Disorders Resource Center.

Diagnostic criteria for bulimia nervosa

DMS-5 diagnostic criteria for 307.51 (F50.2) BN are as follows: [1]

  • Recurrent episodes of binge eating: An episode of binge eating is characterized by both (1) eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances and (2) a sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)

  • Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise

  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

  • Self-evaluation is unduly influenced by body shape and weight

  • The disturbance does not occur exclusively during episodes of AN

Specify if either of the following applies:

  • In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time

  • In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria has been met for a sustained period of time

Specify current severity. The minimum level of severity is based on the frequency of inappropriate compensatory behaviors. The level of severity may be increased to reflect other symptoms and the degree of functional disability. Specify current severity as follows:

  • Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week

  • Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week

  • Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week

  • Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week

Case study

A 21-year-old woman is brought into an outpatient clinic by her mother, who complains that her daughter has been demonstrating unusual eating patterns since she moved back home 6 months ago. Her mother observes her to eat large amounts of food, such as desserts, when she is alone, often finding food wrappers hidden in her daughter’s room. She is worried that her daughter may be engaging in vomiting after these episodes of heavy eating. She often isolates herself in the bathroom for 10–20 minutes after a large meal. This case will be discussed in the Clinical History section.

Other problems to be considered

Binge-eating disorder (BED)

BED is characterized by frequent and recurrent binge eating episodes without consistent compensatory behaviors. It is the most common eating disorder overall, with a lifetime prevalence of 2.8%. BED is known to have several comorbidities with other psychiatric disorders, and is strongly associated with severe obesity. The lifetime prevalence for BED in men is 2%, while the male prevalence of BN is 0.5% and AN is 0.3%. This makes BED the most common eating disorder not only in the general population, but in men, as well. [10]

A meta-analysis of 45 studies found only moderate support for the efficacy of cognitive-behavioral therapy (CBT) and CBT guided self-help, and modest support for interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRI), and lisdexamfetamine in the treatment of adults with BED in terms of cessation of or reduction in the frequency of binge eating. [11]

Night eating syndrome (NES)

NES has only recently been defined and recognized. It is characterized by the consumption of large amounts of food (>20% of the total calorie intake) after evening meals. It is typically associated with early morning drowsiness and anorexia. No significant overlap is seen between BED or BN and night eating disorder.

Several eating disorder syndromes have been described in association with disturbances in disturbances in sleep and circadian patterns. These disorders are diagnosed under the DSM-5-TR “Other Specified Feeding or Eating Disorders” category. [1]

NES is distinct from sleep-related eating disorder (SRED), another syndrome in which eating and sleep disturbances have been linked. NES and SRED are quite different. NES could be considered an abnormality in the circadian rhythm of meal timing with a normal circadian timing of sleep onset, ie, with individuals eating a substantial part of their daily intake in the evening, after usual dinnertime, before they go to sleep. Conversely, the feeding behavior in SRED is characterized by recurrent episodes of eating after an arousal from nighttime sleep with or without amnesia.

In addition to eating other foods, in SRED episodes, patients will sometimes eat foods that are ordinarily unpalatable, eg, raw flour and raw bacon have been described. Both conditions are often relentless and chronic. SRED is frequently associated with other sleep disorders, in particular parasomnias, eg, sleep-walking. Case reports have linked some cases of SRED to the use of certain psychotropic medications, including tricyclic antidepressants, anticholinergics, lithium, triazolam, olanzapine, risperidone, and zolpidem. Early studies have suggested that the anti-seizure medication topiramate may be an effective treatment for SRED. [12]



United States

Bulimia nervosa (BN) is thought to be significantly underrecognized. In the United States, the prevalence of BN is 1%. [10] Lifetime prevalence is 0.5% for males and 1.5% for females. Those who are diagnosed with BN spend approximately 8.3 years with an episode. Approximately 65.3% of patients with BN have a body mass index (BMI) between 18.5 and 29.9 and only 3.5% have a BMI less than 18.5.

BN is more common among those whose occupation or hobbies require gaining and/or losing weight rapidly, such as wrestlers and competitive bodybuilders. [13] Athletes in certain sports (eg, runners and gymnasts) are particularly prone to eating disorders. [14] Athletes' most frequent hindering factors were negative emotions/cognitions, sport pressures, and hurtful modeling, while non-athletes reported negative emotions/cognitions, lack of support, and hurtful modeling.The female athlete triad of eating disorders, hypothalamic amenorrhea, and osteoporosis is now well recognized and is particularly common in sports where slimness and body shape are of great importance, such as gymnastics, long-distance running, diving, and figure skating. Eating disorders are also being recognized as a problem in predominantly male sports such as cycling, weight lifting, and wrestling. Certain vocations such as acting, modeling, and ballet dancing [15] also appear to be associated with higher risk for these disorders.

While overall epidemiological trends are difficult to assess given the changes in diagnostic criteria over time, most studies report a progressive increase in the prevalence of AN and BN in the last several decades of the twentieth century, with the possibility that rates have been leveling off. However, along with increases in obesity, rates of BED are believed to be on the rise as well.

Rates of bulimic symptoms (as distinct from the diagnosis of BN per se) may vary across geographic regions in the United States. In one small study, women from North Carolina and Virginia (South Atlantic region) reported more bulimic symptoms than women from Louisiana and Tennessee (South Central region) and Ohio and Missouri (Midwest region). [16]



A meta-analysis conducted of 36 studies by Arcelus et al suggests that individuals with eating disorders have significantly elevated mortality rates. Furthermore, the patients with anorexia nervosa (AN) had the highest mortality rate. [17]


Bulimia nervosa (BN) is a cosmopolitan disorder that has been described in all ethnic, racial, and socioeconomic groups. Literature is mixed regarding ethnic differences in eating disorders. No clear consensus exists about the relative prevalence of eating disorders and associated symptoms across ethnicities. Clinicians should remain alert for possible ethnic diversity in symptom presentation or distress that could obscure the diagnosis or need for intervention. [18, 19]

Despite efforts to understand racial/ethnic differences, relatively few eating disorder models address the important sociocultural factors that exert powerful influences on beliefs and behaviors related to weight status and eating patterns in this population. Non-traditional research designs are exploring culture-specific risk factors for eating disorders (eg, African American adolescents).


As with other eating disorders, BN occurs predominantly in women. Most reports suggest a female-to-male ratio of 10:1, with reported ranges from 20:1 to 7:1. In some populations (eg, active duty military) body dissatisfaction and subclinical eating disorder rates among males have been reported to be in excess of 20%.

Clinicians should remain aware that men also develop BN and other eating disorders. The psychopathology and attitudes of males with eating disorders appear on the whole to be similar to those of females with eating disorders; both are significantly associated with family histories of these disorders. Although few data are available, evidence suggests that men and women also share significant similarities in clinical course, complications, and response to treatment.


The mean age of onset is 19.7, slightly older than the peak age of onset for AN but generally lower than the age of onset for binge-eating disorder. The prevalence of BN in children younger than 14 years appears to be less than 5%. BN has also been reported in the elderly. [20]



Despite the major public health burden of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED), there is lack of evidence on the differences in the health-related quality of life (HRQoL) and economic impact of different eating disorders (EDs).

A systematic review of 69 studies in the published literature on the HRQoL and economic burdens found that 17 types of HRQoL instruments were applied, including the Medical Outcome Study Short Forms (ie, Short Form 36 [SF-36] and Short Form 12 [SF-12]) alone or in combination with others. [21]  Patients with AN, BN, and BED were shown to have significantly lower HRQoL than the general population. For example, the BN patients had lower scores on the role emotional, social functioning, mental health, vitality, and general health scales than the non-ED subjects, and the BED patients had lower scores on the role emotional, mental health, and vitality scales than the non-ED subjects. In terms of economic burden, AN (78%), BN (88%), and BED (73%) were associated with increased health service use (for any treatment, lifetime) compared with individuals without an ED (44%). The health service use in AN was reported to be equal to or higher than in BN or BED in many studies, and the biggest difference in healthcare utilization was higher hospitalization for AN compared to BN patients was largest, along with a longer length of hospital stay for AN (15.0–52.7 days) than for BN (9.0–45.7 days).

Research to date suggests a variable prognosis. The illness may pursue a long-term, fluctuating course over many years, or may be more episodic, associated with stressful life events and crises. The diagnosis may not be stable over time. [22]  In the shorter term, some reports suggest a 50% improvement in binge eating and purging behavior among patients who are able to engage in treatment. In a 12-year outcome study that looked at bulimia nervosa, purging type, 28.2% of the individuals maintained the diagnosis of bulimia nervosa, purging type. Psychiatric comorbidities predicted poor outcome, specifically self-injurious behaviors. [23]

In 2008, a 10-year follow-up study was published that looked at parental psychopathology as a source of predicted outcome. The paper found that substance abuse in fathers and depression in mothers was associated with poor outcome. Obesity in mothers was associated with a better long-term outcome. [24]

Most eating disorders have high recovery in the first 10 years of the disease development. However, bulimia nervosa, as compared to other eating disorders, is the only eating disorder that has increased probability of recovery past 10 years. [25]  This is in contrast to those with prolonged anorexia nervosa, whose chance of recovery decreases with increasing length of disease. In another study that examined temporal patterns of recovery in bulimia nervosa, 10% of those with bulimia nervosa met recovery criteria at 10 years. At 15 years, 25% met recovery criteria. The patients had 3 times the rate of recovery at 10-14 years than matched patients with anorexia nervosa. [10]  Literature is growing about the long-term outcome of bulimia. In a 5-year longitudinal study, patients with bulimia nervosa had a remission rate of approximately 74% and a relapse rate of approximately 47%. The natural course did not appear to be influenced by personality disorder psychopathology. [26]

Consistent predictors of outcome have not yet been identified. However, the severity of the purging sequelae, negative self-image, [27]  childhood maltreatment, [28]  childhood obesity/overeating, [29]  individual/family eating patterns during childhood/early adolescence, [30]  and ADHD [31]  may be important indicators of worse prognosis. Depression may also be associated with a worse outcome. Electrolyte imbalances, esophagitis, and hyperamylasemia reflect more severe purging and may predict a poorer outcome.

Lifetime history of anorexia nervosa maybe an important indicator of prognosis in patients with bulimia nervosa. In a 9-year longitudinal study, when compared to women with bulimia nervosa who have no history of anorexia nervosa, patients diagnosed with bulimia nervosa and with a history of anorexia nervosa were more likely to cross back into anorexia nervosa and were less likely to achieve full recovery. [32]


Patient Education

Cognitive behavioral therapy remains the therapeutic method of choice for bulimia nervosa, and various modifications of this technique are actively under investigation. Most of these interventions include the premise that education about bulimia nervosa in a nonthreatening environment has a therapeutic effect. These types of therapy are conducted in either individual or group settings. Educational components of treatment address the following issues:

  • The multifactorial etiology of eating disorders with biologic, genetic, psychological, familial, and sociocultural factors

  • Medical complications related to vomiting, laxative, and diuretic abuse

  • The set-point theory of weight regulation and the potential consequences of weight cycling and cyclic dieting

  • Basic nutritional information

  • Sociocultural and body image issues

  • Cognitive and behavioral strategies

  • Relapse prevention and management of occasional binge eating "slips"

More than 70% of published management studies of bulimia nervosa involve some form of psychoeducational program. Although no “unbundling” studies have been conducted that exclude psychoeducation to assess the relative contribution of this specific strategy to overall treatment outcomes, anecdotal reports and the personal experiences of many practitioners suggest that for at least some patients the educational information helps significantly.

Family members can provide perspectives on factors contributing to the onset of the disorder and issues that may help or hamper recovery efforts, and their involvement is often critical to sustained recovery. In addition to empathically listening to family members, clinicians should educate and advise them on the nature of the disorder and their interactions with the patient. When indicated, and with the patient’s consent, families should be involved in treatment. Such involvement may contribute to the likelihood of better outcomes. [8]

For excellent patient education resources, visit eMedicineHealth's Women's Health Center. Also, see eMedicineHealth's patient education article Bulimia.

For further information, see the following Web sites:

Below is a list of workbooks and books for bulimia nervosa:

  • Sandoz E, Wilson K, Dufrene T: The Mindfulness and Acceptance Workbook for Bulimia: A Guide to Breaking Free from Bulimia using Acceptance and Commitment Therapy. Oakland, CA, New Harbinger Publications, Inc, 2011

  • Astrachan-Fletcher E, Maslar M: The Dialectical Behavior Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. Oakland, CA, New Harbinger Publications, Inc, 2009

  • Miller C: My Name Is Caroline, second edition. New York, Cogent Publishing, 2014

  • Miller C: Positively Caroline. New York, Cogent Publishing, 2013

  • Feigenbaum N: Maintaining Recovery From Eating Disorders: Avoiding Relapse and Recovering Life. London, UK, Jessica Kingsley Publishers, 2012

  • DeSole L: Eating Disorders and Mindfulness: Exploring Alternative Approaches to Treatment. New York, Routledge, 2014

  • Fairburn C: Overcoming Binge Eating, second edition. New York, Guilford, 2013

  • Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): second edition, A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 2015

Other books reported to be helpful by patients/families include the following:         

  • Bulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005

  • Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005

  • Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005