Bulimia Nervosa

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Bulimia nervosa (BN)\: eating disorder characterised by binge eating and compensatory behaviours (self-induced vomiting,
laxatives, heavy exercise). It is most common in women aged 20-30, with peak onset at 15-25 years; prevalence in Europe
under 1-2%.
Aetiology\: multifactorial (genetic, social, psychological factors); 3.7 times increased risk with a relative having BN.
Risk factors\:
Genetic\: family history of eating disorders, mental illness, impulse control disorders.
Psychosocial\: prior mental health diagnosis, poor self-esteem, history of abuse/trauma, comorbid impulse control disorder,
appearance-dependent career/hobby, history of restrictive/binge cycles.
Symptoms\:
Binge eating, distress over body image, low self-esteem.
Frequent bathroom trips post-meals, uncomfortable eating with others.
Ritualistic eating/exercise habits, use of metabolism-altering substances.
Mood
Purging behaviours\: binge eating followed by self-induced vomiting, strenuous exercise, laxatives, enemas, diuretics.
Screening questionnaires\: SCOFF questionnaire, EDE-Q 6.0 for assessing eating behaviours.
Risk assessment\: evaluate for self-harm, suicidal actions, self-neglect, coexisting mental health disorders.
Clinical
glands, sore throat, mouth ulcers, halitosis, re
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compulsive disorder.
Investigations\:
Bedside\: BMI calculation, basic observations, blood glucose, urinalysis, ECG.
Laboratory\: U&E (hypokalaemia, increased creatinine, alkalosis), magnesium, FBC, LFTs.
ICD-11 criteria\: frequent binge eating episodes, repeated compensatory behaviours, preoccupation with weight/shape,
impairment in functioning, not meeting anorexia nervosa criteria.
Management\:
Biological\: SSRIs (
Psychological\: cognitive behavioural therapy (CBT), family therapy for children.
Social\: education for patient/family, support resources (e.g., Beat website).
Complications\: irregular menstrual cycles, fertility issues, mental health conditions (depression, anxiety), gastric ulcers,
osteoporosis, cardiovascular issues (arrhythmias, heart attacks, heart failure, cardiomyopathy).
Recovery rates\: 45% fully recover, 27% signi
Article 🔍
A comprehensive topic overviewIntroduction
Bulimia nervosa (BN) is an eating disorder characterised by episodes of binge eating, where a person su
control and eats more than usual.
This often goes alongside compensatory mechanisms to prevent excess weight gain. These can include self-induced
vomiting, using laxatives and heavy exercise.
1
Bulimia is most common in women in their 20s and 30s. 2
bulimia is reported to be under 1-2%.
3
The peak age of onset is age 15-25. In Europe, the prevalence of

Aetiology

The aetiology of eating disorders isn't fully understood, but we know that there is not a single de
development of bulimia.
Numerous genetic, social and psychological factors often play a role in the development of an eating disorder, for
example, there is a 3.7 times increased risk of developing BN if a relative has the disorder.

Risk factors

There are often numerous factors that contribute to a person developing bulimia.
Genetic risk factors for bulimia include\:
Family history of eating disorders
Family history of mental illness
Family history of impulse control disorders
Psychosocial risk factors for bulimia include\:
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Prior mental health diagnosis
Poor self-esteem
History of abuse or trauma
Co-morbid impulse control disorder
Having a career or hobby dependent on appearance
History of engaging in restricting and bingeing cycles

Clinical features

History
Typical symptoms of bulimia nervosa may include\:
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Engaging in binge eating behaviours
Distress over body image
Low self-esteem
Frequent bathroom trips following meals
Uncomfortable eating food in the presence of others
Ritualistic eating habits and exercise routines
Use of substances to manipulate metabolism\: anabolic, stimulants, thyroxine
Mood
Irritability\: around food, questions about food, anticipation of meals
Shame, embarrassment and guilt over binging
Intrusive thoughts about needing to binge
Intrusive thoughts
(consumption of a large volume of often restricted foods in one sitting) followed by ‘purging’ behaviours such as self-
induced vomiting, strenuous exercise, using laxatives, enemas or diuretics to counteract their food binge.
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These binges can be objective (i.e. a large amount of food for even a healthy individual) or subjective (i.e. the amount
consumed is not a lot compared to a healthy individual but is to the su
Additionally, binges can occur even when the individual is not physically hungry and often continue to a painful point
beyond the state of physical fullness.
Other important areas to cover in the history include\:
Past medical history\: including any past psychiatric diagnoses or admissions and any medical conditions (particularly of
diabetes)
Drug history\: regular and over-the-counter medicine (e.g. laxatives)
Social history\: social support networks, family circumstances, alcohol and drug use
Screening questionnaires
While they don't provide a de
have an eating disorder such as bulimia nervosa.
One example of this is the SCOFF questionnaire\:
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Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone (6.35kg) in three months?
Do you believe yourself to be Fat when others say you are too thin?
Would you say Food dominates your life?
Answering "
yes" to two or more questions means that further investigation is needed into a potential eating disorder.
Two further questions can be asked that have a high sensitivity and speci
Are you satis
Do you ever eat in secret?
Another example is the EDE-Q 6.0 (Eating Disorder Examination Questionnaire), which assesses eating behaviours
over the last 28 days.
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Risk assessment
It is important to perform a risk assessment in all patients with a suspected eating disorder, as it is with any mental
health disorder.
This includes determining their risk of self-harm, suicidal actions or self-neglect. It is common for eating disorders
to co-exist with other mental health disorders such as depression and anxiety.
For more information, see the Geeky Medics guide to suicide risk assessment.
Clinical examination
People with bulimia often have normal body weight, which may be accompanied by weight
Typical clinical
Periorbital petechiae post-purging
Tooth erosion
Swollen salivary glands
Sore throatMouth ulcers
Halitosis
Gastro-oesophageal re
Alkalosis\: due to loss of hydrochloric acid from the stomach
Hypokalaemia
Russel’s sign\: calluses on the knuckles where they have scraped against the teeth

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Anorexia nervosa (AN)\: patients with anorexia often present with a severely low BMI, unlike bulimia, where the BMI is
usually normal or raised. In anorexia, there is a restriction of energy intake, whereas in bulimia recurrent episodes of
binge eating with compensatory mechanisms are evident.
Binge eating disorder\: though these individuals do share the pattern of generally secretive episodic binges in response
to emotional distress and feel deep shame around their behaviours, those with binge eating disorder do not engage in
compensatory behaviours to negate the episodes of binging.
Body dysmorphic disorder
Depression
Obsessive-compulsive disorder

Investigations

Bedside investigations
Relevant bedside investigations include\:
Height and weight\: to calculate BMI
Basic observations\: including blood pressure and heart rate
Blood glucose\: may show hypoglycaemia
Urinalysis\: may show ketones if the patient has co-morbid diabetes mellitus. Some patients may skip insulin to control
their weight. This is often referred to as ‘diabulimia’
.
ECG\: important to perform if there is a severe de
increased P wave amplitude, prolonged PR interval, ST depression, T wave
Laboratory investigations
Relevant laboratory investigations include\:
Urea & electrolytes\: these may show hypokalaemia and/or increased creatinine. Elevated bicarbonate usually indicates
alkalosis due to loss of gastric acid.
Magnesium\: may be low
Full blood count\: may show anaemia
Liver function tests\: may be abnormal as excess exercise can elevate aminotransferases

Diagnosis

The ICD-11 criteria for bulimia include the following features\:
1
Frequent recurrent distressing binge eating episodes (> once a week for > 1 month) during which an individual feels a
loss of control overeating
Repeated inappropriate compensatory behaviours to prevent weight gain i.e. laxative abuse, self-induced purging,
excessive exercise, substance misuse
Excessive preoccupation with weight and or shape.
Behaviours and the associated distress are signi
Symptoms do not meet AN criteriaManagement
As with all mental health conditions, it is helpful to think of management as a biopsychosocial approach, this helps to
ensure that management is holistic.
Biological therapies
Selective serotonin-reuptake inhibitors (SSRIs) are used for the pharmacological management of bulimia. Fluoxetine is
typically used
These may be used when cognitive behaviour therapy (CBT) isn’t available or when it has been tried and the patient hasn’t
seen any improvement.
The medications should be given at a time of day when they are unlikely to be purged.
2
SSRIs are also useful in the case of comorbid disorders (e.g. depression and anxiety).
Psychological therapies
Cognitive behavioural therapy is seen as the optimal
and meal support (delivered by a trained dietician).
Children with bulimia should be o
2
Social therapies
It is important to provide education about bulimia to the patient and their family. Online resources such as the Beat
website are useful sources of patient information and support.
Diabetes and bulimia
Patients with diabetes need input from an endocrinologist for glycemic control and insulin management. Admission
to hospital may be required.
2

Complications

Complications of bulimia include\:
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Irregular menstrual cycles and fertility issues
Mental health conditions such as depression and anxiety
Gastric ulcers
Osteoporosis
Cardiovascular issues, including arrhythmias, heart attacks or failure and cardiomyopathy
In terms of recovery, 45% do so fully, 27% make signi
disorder.

References

ICD-11. B u l i m i a n e r v o s a . 2021. Available from\: [LINK]
BMJ Best Practice. B u l i m i a n e r v o s a . 2021. Available from\: [LINK]
NICE CKS. E a t i n g d i s o r d e r s \: H o w c o m m o n i s i t ? 2019. Available from [LINK]
Eating Disorder Hope. W h a t i s b u l i m i a \: S y m p t o m s , C o m p l i c a t i o n s a n d C a u s e s . Available from\: [LINK]
The BMJ. The SCOFF questionnaire\: assessment of a new screening tool for eating disorders. 1999. Available from\: [LINK]Inside Out. Eating Disorder Examination Questionnaire. 2023. Available from\: [LINK]

Reviewer

Dr William Davies
Psychiatry Registrar (ST6)
Dr Louisa Ward
CAMHS SpR

Related notes

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Medically Unexplained Symptoms
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Contents

Introduction
Aetiology
Risk factors
Clinical features
Di
Source\: geekymedics.com