Bulimia nervosa
Bulimia nervosa is an eating disorder marked by recurrent binge eating with recurrent inappropriate compensatory behavior, such as self-induced vomiting, laxative misuse, fasting, or excessive exercise, occurring at least once weekly for 3 months in a patient whose weight is typically normal or above (body mass index above 18.5 kg/m2), which separates it from the binge-purge subtype of anorexia nervosa. The diagnosis is clinical; first-line treatment is cognitive behavioral therapy plus fluoxetine 60 mg PO once daily, avoiding bupropion because of an increased seizure risk.
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What this article covers
- Overview
Definition: bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by recurrent inappropriate compensatory behavior to prevent weight gain, occurring at…
- Epidemiology
Sex and onset: prevalence is about three times greater in women than in men, and the median age of onset is 18 years.
- Risk factors
Female sex: the strongest demographic risk factor, with prevalence about three times that of men.
- Pathophysiology
The binge-purge cycle drives the physical findings: repeated large-volume eating followed by a compensatory behavior underlies essentially all of the downstream physical complications.
- Clinical features
Diagnostic criteria: recurrent episodes of binge eating (eating an objectively large amount of food within a discrete period, with a sense of loss of control) plus recurrent inappropriate…
- Differential diagnosis
Anorexia nervosa, binge-purge subtype: shares binge eating and purging, but BMI is below 18.5 kg/m2, whereas bulimia nervosa's weight is normal or above.
- Diagnosis
Diagnostic basis: the diagnosis is clinical, confirmed when a patient meets the criteria above (recurrent binge eating with recurrent compensatory behavior at least once weekly for 3 months…
- Management
First, address any medical emergency: hospitalize for intravenous fluid and electrolyte repletion if vital signs are unstable, the patient is significantly dehydrated, or the metabolic panel shows a significant electrolyte disturbance.
- Complications
Esophagogastric injury: repeated forceful retching produces a Mallory-Weiss tear, a partial-thickness mucosal laceration at the gastroesophageal junction; rarely, severe retching progresses to esophageal perforation (Boerhaave syndrome).
- Prognosis
Better than anorexia nervosa, but not benign: prognosis is more favorable than anorexia nervosa, though patients with bulimia nervosa still carry an elevated suicide risk.
- Prevention
Continue antidepressant therapy for relapse prevention: after remission, continue fluoxetine at the effective dose for continuation and maintenance, often 6 to 12 or more months, since untreated bulimia nervosa tends toward chronicity.
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- Anorexia nervosa
Anorexia nervosa is restriction of energy intake driven by an intense fear of weight gain and a distorted body image, producing a body mass index below 18.5 kg/m2 with bradycardia, hypotension, hypothermia, amenorrhea, and osteoporosis. Diagnosis is clinical; management starts with medical stabilization and slow, monitored nutritional rehabilitation to avoid refeeding syndrome, followed by family therapy in adolescents, with olanzapine as adjunctive pharmacotherapy and bupropion avoided for its seizure risk.
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.
- Borderline personality disorder
Borderline personality disorder is a cluster B personality disorder defined by 5 or more of 9 DSM-5 criteria spanning instability of relationships, self-image, and affect, marked impulsivity, and recurrent self-injury or suicidality; dialectical behavior therapy is the first-line treatment, with pharmacotherapy reserved as a secondary, symptom-targeted adjunct.
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Gastroparesis
Gastroparesis is delayed gastric emptying without mechanical obstruction, most often from longstanding diabetes, prior gastric surgery, or an idiopathic postviral course, presenting with nausea, vomiting, early satiety, and postprandial fullness. Diagnosis requires upper endoscopy to exclude obstruction followed by objective gastric emptying testing, and management progresses from glycemic control and dietary change through time-limited prokinetics to device or endoscopic therapy for refractory disease.
- Mallory-Weiss syndrome
Mallory-Weiss syndrome is a partial-thickness, longitudinal mucosal tear at the gastroesophageal junction caused by forceful retching or vomiting, classically presenting as hematemesis after an initial bout of non-bloody vomiting in a patient with alcohol use disorder or bulimia. Upper endoscopy is both diagnostic and therapeutic, most tears stop bleeding spontaneously, and active bleeding is controlled endoscopically.