Bulimia Nervosa

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  • Binge eating is characterized by eating, in a discrete period of time (within 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and a sense of lack of control over eating during the episode, followed by recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, excessive exercise, and so forth.
  • Binge eating and inappropriate compensatory behaviors both occur once a week for 3 months.
  • DSM-5 classifies bulimia nervosa severity as the following:
    • Mild: 1 to 3 episodes of inappropriate compensatory behaviors per week
    • Moderate: 4 to 7 episodes of inappropriate compensatory behaviors per week
    • Severe: 8 to 13 episodes of inappropriate compensatory behaviors per week
    • Extreme: 14 or more episodes of inappropriate compensatory behaviors per week
  • System(s) affected: oropharyngeal, endocrine/metabolic, gastrointestinal, dermatologic, cardiovascular, pulmonary, psychiatric


  • Predominant age: adolescents and young adults
  • Mean age of onset: 18 to 21 years
  • Predominant sex: female > male (13:1)

28.8 women, 0.8 men per 100,000 per year

  • More prevalent than anorexia nervosa
  • 1.5% in women age 16 to 35 years
  • 0.5% in young men

Etiology and Pathophysiology

  • Combination of biologic, psychological, environmental, and social factors. Unique contribution of any specific factor remains unclear.
  • Strong evidence of serotonergic dysregulation in bulimia nervosa
  • Substantial literature shows genetic evidence for bulimia nervosa.
  • Multiple studies demonstrate altered brain function and structure in bulimia nervosa.

Risk Factors

  • Female gender
  • History of obesity and dieting
  • Body dissatisfaction: critical comments about weight, body shape, or eating: low self-esteem
  • Severe life stressor
  • Perfectionist or obsessive thinking
  • Poor impulse control, substance abuse
  • Environment stressing high achievement, physical fitness (e.g., armed forces, ballet, cheerleading, gymnastics, or modeling): perceived pressure to be thin
  • Family history of substance abuse, affective disorders, eating disorder, or obesity
  • Type 1 diabetes
  • Childhood trauma (sexual abuse)

General Prevention

  • Prevention programs can reduce risk factors and future onset of eating disorders.
  • Target adolescents and young women ≥15 years.
  • Realistic and healthy weight management strategies and attitudes
  • Decrease body dissatisfaction and promote self-esteem.
  • Reduce focus on thin as ideal.
  • Decrease anxiety/depressive symptoms and improve stress management.

Commonly Associated Conditions

  • Major depression and dysthymia
  • Anxiety disorders
  • Substance use disorder
  • Bipolar disorder
  • Obsessive-compulsive disorder
  • Borderline personality disorder

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