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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 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).
- Characteristic clinical features
- BMI: can be normal or slightly elevated
|Associated features of bulimia nervosa |
|Central nervous system|
Bulimia nervosa is associated with an increased risk of suicide. 
General principles 
- See “Screening for eating disorders” for indications and screening modalities.
- Determine if individuals fulfill all of the DSM-5 diagnostic criteria for bulimia nervosa to confirm the diagnosis.
- Evaluate for complications and comorbidities, and rule out possible organic etiologies for change in weight and/or eating behaviors: See “Initial evaluation for a suspected eating disorder.”
DSM-5 diagnostic criteria 
|DSM-5 diagnostic criteria for bulimia nervosa |
|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. 
Severity (according to DSM-5) 
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
General principles 
- Evaluate for .
- Determine appropriate care setting; see “Disposition for eating disorders.”
- Discuss treatment goals, e.g.: 
- Decrease the number of episodes of inappropriate weight compensatory behaviors.
- Improve disordered thoughts and beliefs (e.g., about body image, self-esteem, eating behaviors).
- Identify and manage complications: See “Clinical features”, and “Laboratory studies” in “Diagnostics.”
- Comanage nutritional management with a dietitian.
- Provide nutritional education.
- Promote healthy eating habits.
- Refer all patients for psychotherapy; consider pharmacotherapy only as adjunctive therapy.
- Regularly reassess for remission. 
Nutritional management 
- Evaluate nutritional intake.
- Educate and support patients to implement healthy eating habits, including binge eating prevention strategies.
- For underweight patients, guidance in may be appropriate. 
First-line therapy for bulimia nervosa
Adolescents and young adults
- Family-based therapy with an involved caregiver (preferred)
- Cognitive behavioral therapy
- Guided self-help programs
- Adults: may consider either of the following 
- 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. 
- Fluoxetine 
- Other SSRIs
If patients do not experience symptom improvement with pharmacotherapy, determine whether the medication is being taken shortly before episodes of vomiting. 
We list the most important complications. The selection is not exhaustive.
- Course: chronic with relapses 
- Mortality: 2–6 times higher than the general population 
- Increased risk of psychological comorbidities 
Bulimia nervosa can transition to anorexia nervosa and vice versa.