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Bulimia Nervosa

by Evelyn Attia, MD, B. Timothy Walsh, MD

Bulimia nervosa is characterized by recurrent episodes of binge eating followed by some form of inappropriate compensatory behavior such as purging (self-induced vomiting, laxative or diuretic abuse), fasting, or driven exercise; episodes must occur at least 1 time/wk for 3 mo. Diagnosis is based on history and examination. Treatment is with psychologic therapy and antidepressants.

Bulimia nervosa affects about 1.6% of adolescent and young women and 0.5% of men of comparable age. Those affected are persistently and overly concerned about body shape and weight. Unlike patients with anorexia nervosa, those with bulimia nervosa are usually of normal or above-normal weight.


Serious fluid and electrolyte disturbances, especially hypokalemia, occur occasionally. Extremely rarely, the stomach ruptures or the esophagus is torn during a binge or purge episode, leading to life-threatening complications.

Because substantial weight loss does not occur, the serious nutritional deficiencies that occur with anorexia nervosa are not present. Cardiomyopathy may result from long-term abuse of syrup of ipecac if used to induce vomiting.

Symptoms and Signs

Patients typically describe binge-purge behavior. Binges involve rapid consumption of an amount of food definitely larger than most people would eat in a similar period of time under similar circumstances (eg, the amount considered excessive for a normal meal vs a holiday meal may differ) accompanied by feelings of loss of control.

Patients tend to consume sweet, high-fat foods (eg, ice cream, cake). The amount of food consumed in a binge varies, sometimes involving thousands of calories. Binges tend to be episodic, are often triggered by psychosocial stress, may occur as often as several times a day, and are usually carried out in secret.

Binge eating is followed by compensatory behaviors: self-induced vomiting, use of laxatives or diuretics, excessive exercise, and/or fasting.

Patients are typically of normal weight; a minority are overweight or obese. However, patients are excessively concerned about their body weight and/or shape; they are often dissatisfied with their bodies and think that they need to lose weight.

Most symptoms and physical complications result from purging. Self-induced vomiting may lead to erosion of dental enamel of the front teeth, painless parotid (salivary) gland enlargement, and an inflamed esophagus. Physical signs include

  • Swollen parotid glands

  • Scars on the knuckles (from induced vomiting)

  • Dental erosion

Patients with bulimia nervosa tend to be more aware of and remorseful or guilty about their behaviors than those with anorexia nervosa and are more likely to acknowledge their concerns when questioned by a sympathetic clinician. They are also less socially isolated and more prone to impulsive behavior, drug and alcohol abuse, and overt depression. Anxiety (eg, concerning weight and/or social situations) and anxiety disorders may be more common among these patients.


  • Clinical criteria

Clinical criteria for diagnosis include the following:

  • Recurrent episodes of binge eating (the uncontrolled consumption of unusually large amounts of food) that are accompanied by feelings of loss of control over eating and that occur at least once/wk for 3 mo

  • Recurrent inappropriate compensatory behavior to influence body weight (at least once/wk for 3 mo)

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


  • Cognitive-behavioral therapy (CBT)

  • Interpersonal psychotherapy (IPT)

  • SSRIs

CBT is the treatment of choice. Therapy usually involves 16 to 20 individual sessions over 4 to 5 mo, although it can also be done as group therapy. Treatment aims to increase motivation for change, replace dysfunctional dieting with a regular and flexible pattern of eating, decrease undue concern with body shape and weight, and prevent relapse. CBT eliminates binge eating and purging in about 30 to 50% of patients. Many others show improvement; some drop out of treatment or do not respond. Improvement is usually well-maintained over the long-term.

In IPT, the emphasis is on helping patients identify and alter current interpersonal problems that may be maintaining the eating disorder. The treatment is both nondirective and noninterpretive and does not focus directly on eating disorder symptoms. IPT can be considered an alternative when CBT is unavailable.

SSRIs used alone reduce the frequency of binge eating and vomiting, although long-term outcomes are unknown. SSRIs are also effective in treating comorbid anxiety and depression. Fluoxetine 60 mg po once/day is recommended (this dose is higher than that typically used for depression).

Key Points

  • Bulimia nervosa involves recurrent episodes of binge eating followed by inappropriate compensatory behavior such as self-induced vomiting, laxative or diuretic abuse, fasting, or excessive exercise.

  • Unlike patients with anorexia nervosa, patients rarely lose much weight or develop nutritional deficiencies.

  • Recurrent self-induced vomiting may erode dental enamel and/or cause esophagitis.

  • Cognitive-behavioral therapy is used, sometimes along with an SSRI.

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