Bulimia Nervosa

Bulimia Nervosa

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Bulimia nervosa is an eating disorder characterized by episodes of binge eating, where a person feels out of control and eats more than usual. This usually occurs in combination with compensatory mechanisms to prevent weight gain, including self-induced vomiting, laxative use, and excessive exercise.

Bulimia is most common in women between the ages of 20 and 30. In Europe, its prevalence is under 1-2%.


The causes of eating disorders are not fully understood, but multiple genetic, social, and psychological factors may contribute to the development of bulimia.

Risk Factors

A number of risk factors can lead to the development of bulimia, including:

  • Family history of eating disorders, mental illness, or impulse control disorders
  • Prior mental health diagnosis
  • Poor self-esteem
  • History of abuse or trauma
  • Career or hobby dependent on appearance
  • History of restrictive and binge eating cycles

Clinical Features


Symptoms of bulimia may include:

  • Engaging in binge eating
  • Concerns over body image
  • Frequent trips to the bathroom after eating
  • Uncomfortable eating around others
  • Mood swings, depression, suicidal thoughts, and self-harming behaviour

The term 'purging' is used to refer to binge eating followed by actions such as self-induced vomiting, heavy exercise, laxatives, enemas or diuretics. Other areas to consider in the history may include:

  • Past medical history, mental health diagnoses, and medical conditions
  • Drug history, including regular and over the counter medicine
  • Social history, such as social support, family circumstances, and alcohol/drug use

Clinical Examination

It is important to perform a risk assessment in all patients with suspected eating disorders. This includes assessing risk of self-harm, suicidal behavior, or self-neglect. Eating disorders are commonly accompanied by other mental health disorders such as depression and anxiety.

Clinical Findings in Bulimia Nervosa

People with bulimia nervosa may present with a variety of clinical findings, such as weight fluctuations, tooth erosion, swollen salivary glands, mouth ulcers, gastro-oesophageal reflux, alkalosis, hypokalaemia, and Russell's sign.

Differential Diagnoses

Differential diagnoses for bulimia nervosa include anorexia nervosa, body dysmorphic disorder, depression, and obsessive-compulsive disorder. Anorexia nervosa is distinguished from bulimia by a low body mass index, compared to a normal body mass index in bulimia, and restrictive energy intake rather than recurrent episodes of binge eating.


Bedside Investigations

Relevant bedside investigations include height and weight measurements to calculate body mass index, basic observations such as blood pressure and heart rate, urinalysis for ketones, and an electrocardiogram to detect hypokalaemia.

Laboratory Investigations

Laboratory investigations may include urea and electrolyte tests to measure hypokalaemia and creatinine, a full blood count, and liver function tests.


The criteria for diagnosis of bulimia nervosa according to International Classification of Diseases (ICD)-11 include a preoccupation with controlling body weight, repeated bouts of overeating, and compensatory behaviors after overeating, such as self-induced vomiting, the use of laxatives, and excessive exercise, occurring at least once weekly for at least three months.


Management of bulimia nervosa follows a biopsychosocial approach to ensure a holistic treatment plan. Biological therapies such as selective serotonin-reuptake inhibitors (SSRIs) are used in pharmacological management, most commonly fluoxetine and, if poorly tolerated, sertraline. Psychological therapies such as cognitive behavioral are the optimal first-line treatment.

Bulimia Nervosa

Children with bulimia should be offered a family therapy that is focused on bulimia nervosa.

Social Therapies

It is important to provide education about bulimia to the patient and their family. Online support and information can be found on the Beat website.


Complications associated with bulimia include:

  • Irregular menstrual cycles and fertility issues
  • Mental health conditions such as depression and anxiety
  • Gastric ulcers
  • Osteoporosis
  • Heart issues including arrhythmias, heart attacks or failure and cardiomyopathy


  1. ICD-11. Bulimia nervosa. (2021). Available from: LINK
  2. BMJ Best Practice. Bulimia nervosa. (2021). Available from: LINK
  3. NICE CKS. Eating disorders: How common is it?. (2019). Available from LINK
  4. Eating Disorder Hope. What is bulimia: Symptoms, Complications and Causes. Available from: LINK

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