Bulimia Nervosa

Reviewed by Amy Baker Dennis, PhD, FAED

Bulimia nervosa (BN) is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

Diagnostic Criteria


According to the DSM-5 TR, the official diagnostic criteria for bulimia nervosa is:1

  • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
    • Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
  • Recurrent inappropriate compensatory behavior 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 three months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.

Warning Signs and Symptoms of Bulimia Nervosa


Please note that even though these are common symptoms not everyone with bulimia nervosa displays all of these emotional and behavioral symptoms.

Emotional and Behavioral Signs and Symptoms:1

  • Preoccupied with weight, shape and appearance leading to restriction/dieting behaviors to promote weight loss
  • Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
  • Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
  • Appears uncomfortable eating around others
  • Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)
  • Skips meals or takes small portions of food at regular meals
  • Engaging in fad diets, the elimination of whole food groups, vegetarianism/veganism in service of weight loss.
  • Engages in episodes of binge eating large amounts of food in a short period of time, often in secret
  • After episodes of binge eating, frequently engages in compensatory behaviors such as self-induced vomiting, diuretic/laxative use, fasting/restricting, excessive exercise or manipulation of insulin dosage
  • Withdraws from friends and previously pleasurable activities and becomes more isolated and secretive
  • Fear of eating in public or with others
  • Steals or hoards food in strange places
  • Drinks excessive amounts of water or non-caloric beverages
  • Uses excessive amounts of mouthwash, mints, and gum
  • Hides body with baggy clothes
  • Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories
  • Creates lifestyle schedules or rituals to make time for binge-and-purge sessions
  • Withdraws from usual friends and activities
  • Frequent checking in the mirror for perceived flaws in appearance
  • Extreme mood swings
  • Evaluates self-worth based on weight, shape and appearance
  • Experiences shame, guilt, and despair after episodes of binge- eating and compensatory behaviors
  • Frequently experiences low self-esteem

Physical Signs and Symptoms:1

  • Noticeable fluctuations in weight, both up and down
  • Body weight is typically within the normal weight range, however some individuals are in larger bodies
  • Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
  • Difficulties concentrating
  • Abnormal laboratory findings (anemia, low thyroid and hormone levels, electrolyte imbalances, low potassium, low blood cell counts, slow heart rate)
  • Dizziness
  • Fainting/syncope
  • Sleep problems
  • Cuts and calluses across the top of finger joints (a result of inducing vomiting)
  • Dental problems due to purging include erosion of enamel; bleeding gums/periodontal disease; temperature sensitivity; cavities; discoloration of teeth; dry mouth; enlarged parotid/submandibular glands and swallowing problems.
  • Dry skin
  • Dry and brittle nails
  • Muscle weakness
  • Yellow skin (in context of eating large amounts of carrots)
  • Menstrual irregularities

Frequent Co-Occurring Conditions


The following are some conditions that frequently co-occur with bulimia nervosa:2

  • Anxiety disorders including generalized anxiety disorder, social anxiety, phobias, panic disorder and post-traumatic stress disorder
  • Depression and other mood disorders
  • Impulse control disorders (risky sexual behaviors, driving while intoxicated, shoplifting, gambling, compulsive spending, etc.)
  • Substance use disorders
  • Self-injurious behaviors (cutting and other forms of self-harm without suicidal intent)

Health Consequences of Bulimia Nervosa


The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.

Some of the most common health consequences of bulimia nervosa include:2,3

  • Electrolyte imbalances: Purging behaviors can lead to electrolyte imbalances, such as hypokalemia (low potassium levels), hyponatremia (low sodium levels), and hypochloremia (low chloride levels). Electrolyte imbalances can cause a variety of symptoms, including fatigue, weakness, muscle cramps, heart arrhythmias, and seizures. In severe cases, electrolyte imbalances can be fatal.
  • Dental problems: The stomach acid in vomit can erode tooth enamel, leading to cavities, tooth decay, and gum disease, Bulimia nervosa can also cause the enlargement of the parotid glands (the salivary glands located in front of the ears), that can distort the facial features.
  • Esophageal problems: Repeated vomiting can damage the esophagus, causing inflammation, ulcers, and tears. In severe cases, these problems can lead to a condition called Barrett’s esophagus, which is a precancerous condition.
  • Heart problems: Repeated vomiting can damage the esophagus, causing inflammation, ulcers, and tears. In severe cases, these problems can lead to a condition called Barrett’s esophagus, which is a precancerous precancerous condition.
  • Kidney problems: Dehydration from purging behaviors can lead to kidney problems, such as kidney stones and kidney failure.
  • Hormonal problems: Bulimia nervosa can disrupt the body’s hormones, leading to menstrual irregularities, infertility, and osteoporosis.

Treatment Considerations


Treating bulimia nervosa (BN) requires working with a multidisciplinary team of health and mental health professionals who have expertise in treating this type of eating disorder. This treatment team may include a physician, psychiatrist, psychotherapist, and dietician.4 Given the serious physical and psychological consequences that can result from eating disorders it is essential to seek professional help as soon as possible. Early intervention has also been shown to be an important factor in improving treatment outcomes.2

Learn more about treatment here.

Learn more about finding treatment providers in your area here.

Sources


[1] American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

[2] Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of eating disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2

[3] Mehler, P. S., & Rylander, M. (2015). Bulimia Nervosa – medical complications. Journal of eating disorders, 3, 12. https://doi.org/10.1186/s40337-015-0044-4

[4] Crone, C., Anzia, D. J., Fochtmann, L. J., & Dahl, D. (2023). The American Psychiatric Association practice guideline for the treatment of patients with eating disorders, Fourth Edition. American Psychiatric Association. Available at: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424865