176 Bulimia Nervosa (307.51)

DSM-IV-TR criteria

A. 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; it is common for more than 10,000 calories to be consumed per binge
  • an abnormal constant craving for food; a sense of a lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
  • eating is usually done in secret

B. Recurrent inappropriate, compensatory behavior in order to prevent weight gain. Such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type:

  • Purging Type: during a current episode of Bulimia Nervosa, the person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, enemas or ipecac, as means of rapidly extricating the contents consumed.
  • Non-purging Type: during a current episode of Bulimia Nervosa, the person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
  • The following six criteria should be met for a patient to be diagnosed with bulimia
    • 1.The patient feels incapable of controlling the urge to binge, even during the binge itself, and consumes a larger amount of food than an average healthy person would normally consume at one sitting.
    • 2.The patient purges him or herself of the recent intake, resorting to vomiting, laxatives, diuretics, exercising, etc.
    • 3. The patient engages in such secretive behavior at least twice per week for three months.
    • 4. The patient is focused upon body image and possesses a desperate desire to appear thin.
    • 5. The patient does not meet the diagnostic criteria for anorexia nervosa
    • 6.The patient is of normal weight or overweight, contrasting with characteristics of anorexia nervosa.

Associated features/ effects

A person with Bulimia Nervosa suffers from “body image disturbance”, which makes them unable to perceive their body size accurately. By having these distorted thoughts about their body, they avoid looking into a mirror. People suffering from bulimia nervosa are usually not noticed right away. They seem normal in appearance and are not noticed as easily as anorexics are in public settings. This is because they engage in binge eating activities privately as a solitary activity. People with bulimia nervosa consume their food at a rapid pace, and this may be present along with depression feelings, environmental influential factors, irritability, and tension in some parts of their life. After a binge episode, feelings of guilt and depression follow, forcing the bulimic into purging behaviors which allows them to regain control of the situation. The actual word, bulimia, is translated as “hunger like an ox.”

They experience fluctuating weight loss, but unlike anorexia nervosa, people with bulimia nervosa are still able to maintain the average weight with respect to their height, so they appear relatively normal. Bulimia nervosa is more of a mental aspect than a physical one such as private eating activities. Compared to the rest of the population or those with regular eating habits, people with bulimia nervosa are still considered to be the thinner individuals. Them also wear loose-fitting clothes in order to hide their bodies.

Research has shown that, if caught in early stages enough and treated in the right way, 80% of people with bulimia nervosa can fully recover. This is because the habits are not formed completely in the mind’s everyday activities schedule. If it is not so branded into the behaviors, one can change the eating habits to normal functioning abilities. Most patients can control the behavior with psychotherapy, counseling, biofeedback training and individual or group psychotherapy. Without treatment complications can be fatal.

These individuals may have scabs or nicks on their knuckles from constantly trying to make themselves vomit. Their teeth and esophagus suffer from the constant presence of acid. The recurrent vomiting can lead to loss of dental enamel, and their teeth may appear chipped and ragged. Excessive vomiting also leads to scratched and discolored fingernails due to the patient sticking them down the throat. Sometimes, the salivary glands become permanently enlarged. Also, a person suffering from bulimia will usually display the often recognized “chipmunk cheeks” because they are inflamed due to repeated vomiting. Amenorrhea and chronic bowel problems are also associated with this eating disorder.

Although it is stereotyped that individuals suffering from anorexia nervosa fear the scale, it is actually bulimics that seem to show the most fear of stepping onto a scale. Because bulimia nervosa sufferers have an exaggerated fear of gaining weight, they tend to avoid weighing themselves.

New findings of associated features

Professors and researchers at the University of Pittsburg Medical Center have found evidence supporting that Nervosa Bulimia may be linked by a biological factor. The researchers suggest that an alteration of brain chemistry contributes to a persons development of bulimia nervosa. Dr. Walter H. Kaye, a professor of psychiatry, states in his journal article that, “Women with bulimia nervosa, when bingeing and purging, are known to have alterations of brain serotonin activity and mood as well as obsessions with perfectionism” (Kaye, et al., 1998). An alteration in serotonin levels could cause one to portray anxious and obsessive behaviors.


  1. The patient’s laboratory blood studies, including measurement of electrolyte levels are abnormal
  2. Patient suffers from recurrent mood swings or depression.
  3. Problems with stomach, esophagus, colon and throat.
  4. Patient has no satisfaction with their body shape and is preoccupied with becoming thin.
  5. Excessive exercising to control weight gain.
  6. Unable to stop binge/purge cycle without intervention.
  7. Dental problems
  8. Frequent weight fluctuation
  9. Fear of weight gain
  10. Build up of fluid with swelling of the parotid glands.

Child vs. adult presentation

Onset is later in both children and adults for anorexia nervosa, and bulimia usually begins in late adolescence or early adulthood. It is usually 15 to 21 years of age that onset is diagnosed or becomes possible to diagnose. It is vital that a clinician has time to evaluate the behaviors of the individuals and the environments they inhabit.

The age of onset for children has recently lowered to 9-12 years. This could be related to the pressures from the media and television. Television shows for kids show the same favorable societal definitions that adult shows provide. The decrease in the age of onset could also be related to the onset of puberty decreasing as well. Because children are beginning to experience puberty sooner, their bodies are also developing at a earlier age. For girls, this means more fat tissue is formed which may possibly cause unhealthy self images to exist at earlier ages. Because these children are so young, the abnormal diet and lack of nutrition can lead to the absence of nutritional essentials for their development.

Gender and cultural differences in presentation

Females are much more likely to suffer from Bulimia Nervosa than males. About 1 male for every 10 females suffers from Bulimia Nervosa. This is because women tend to care more about their appearance than males. There are no cultural differences among patients with Bulimia Nervosa regarding their symptoms.

Cultural differences: In Eastern Asian countries, weight is considered to be an indifferent topic; however, their body structure and diet may reduce the chances of staying thin.


About 1% to 3% of people have reported or been diagnosed with Bulimia Nervosa during their lifetime, and most are female. The male to female ratio is 1 male to 10 females.

There are also new studies being conducted that compare the environmental factors of binging and purging habits on the individuals who have Bulimia Nervosa. One of the studies show that there is a 46% binging variance and a 72% vomiting variance. Showing that because of environmental factors, binging can only occur during certain periods while vomiting can happen more frequently. Also, another study in the UK has shown that Bulimia Nervosa is increasing at high rates, almost doubling in occurrence every year, with a lower frequency of occurrence for Anorexia Nervosa.

Bulimia Nervosa usually begins in late adolescence or early adult life. The binge eating often begins during or after a dieting episode. Disturbed eating behavior lasts for at least several years in clinical samples. The course may be chronic or intermittent, with remission altering with relapses into binge eating. over long term, the symptoms of many seem to diminish. Remission longer than one year is associated with better long-term outcome.

Studies show that only 6% of people suffering from Bulimia Nervosa receive mental health care. Statistics show that there has been a dramatic increase of Bulimia in recent years among women between the ages of 15 and 24.


The cause for this disorder is believed to be less from the desire for food, and more from an interaction between biological, environmental, and psychological factors. Common personality characteristics found in people with this disorder are that they are outgoing, sociable, impulsive, and more sexually active. However, a decrease in sex drive or a person’s libido is also reported along with an increase in suicidal behavior.

There is strong evidence of genetic heritability for people with Bulimia Nervosa. A person is six times more likely to develop the disorder if they have a relative with the disorder. Low levels of serotonin have also been found to have a connection with development of Bulimia Nervosa. There is more familial prevalence of obesity in Bulimia Nervosa, compared to that of Anorexia Nervosa.

Psychological Factors: Bulimia includes an obsession with thinness, a diminished perception of self-worth, and an impaired sense of self-confidence. People with bulimia also associate thinness with success, attractiveness, and happiness.

Comorbid Conditions

Depression, anxiety, phobias or intense fears, and personality disorders such as Histrionic Personality Disorder, Borderline Personality Disorder, and Obsessive Compulsive Personality Disorder, are often associated with Bulimia Nervosa along with other types of eating disorders. Also, insomnia is sometimes coexistent with Bulimia Nervosa due to malnutrition. It is not uncommon for people with Bulimia Nervosa to develop certain addictions like gambling, shoplifting, or alcohol and drug usage. In fact, research shows 9% of the general population use alcohol and drugs, whereas 30-50% of people with eating disorders use them.

Empirically supported treatments

  • Some medications, such as fluoxetine (Prozac) are used to treat mood symptoms (depressive symptoms, mood elevations, binge eating desires) for people who are suffering from Bulimia Nervosa. The most common medications are Tricyclic antidepressants such as Selective Serotonin Re-Uptake Inhibitors (SSRI’s). Medication to treat acid reflux caused by bulimia may also be prescribed. Vitamin and mineral supplements are necessary until signs of deficiency disappear and normal eating patterns are established.
  • Cognitive Behavioral Therapy methods are also conducted to change the mindset of people with Bulimia Nervosa. This method focuses on changing the way patients think about their body image, and can sometimes be done in groups. In addition, restriction to binge-type foods is also used to control people who engage in binge-eating.
  • Family therapy involving communication exercises, conflict resolution, and re-establishing boundaries is used more often than other treatments of Bulimia Nervosa.
  • Individual psychotherapy helps the patient develop self-esteem and assertiveness. This therapy also teaches the patient streamlining social skills and pressure-coping strategies.
  • Hospitalization is helpful for bulimia patients who have extreme eating binges which have caused severe medical problems and health hazards. Patients may also have to be hospitalized if they show signs of being suicidal.




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