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Bulimia Nervosa: Symptoms, Signs & What to Know

Bulimia Nervosa (BN) is an eating disorder characterized by recurrent binge eating followed by compensatory behaviors to prevent weight gain, with self-evaluation unduly influenced by body shape/weight.

Diagnostic Criteria (DSM-5)

  1. Binge Eating: Discrete period, eating >normal amount, sense of lack of control.
  2. Compensatory Behaviors (Purging/Non-Purging):
    • Purging: Self-induced vomiting, laxative/diuretic/enema misuse.
    • Non-Purging: Fasting, excessive exercise, insulin omission (diabulimia).
  3. Frequency: ≥1x/week for 3 months.
  4. Self-Evaluation: Dominated by weight/shape.
  5. Not Anorexia: Does not occur exclusively during AN episodes.

Physical Signs & Complications

  • Dental: Perimolysis (enamel erosion, lingual surfaces), caries, salivary gland enlargement (sialadenosis), xerostomia.
  • Electrolyte/Metabolic: Hypokalemia, hypochloremic metabolic alkalosis (vomiting); hypernatremia, metabolic acidosis (laxatives). → Arrhythmia risk, renal dysfunction.
  • GI: Esophagitis, Mallory-Weiss tears, Boerhaave syndrome (rupture), gastroparesis, constipation, rectal prolapse.
  • Endocrine: Menstrual irregularity/amenorrhea, bone loss.
  • Cardiac: QT prolongation, cardiomyopathy (ipecac), sudden death (electrolyte).
  • Dermatologic: Russell's sign (callus on dorsum of hand from inducing vomiting), lanugo, dry skin.

Psychological Features

  • Intense fear of weight gain, body dysmorphia, shame, secrecy, impulsivity, mood lability, comorbid depression/anxiety/OCD/substance use.

Treatment

  • CBT-E (Enhanced Cognitive Behavioral Therapy): First-line. Addresses dietary restraint, cognitive distortions, emotional regulation.
  • Medication: Fluoxetine 60 mg (only FDA-approved for BN) — reduces binge/purge frequency.
  • Nutritional Rehabilitation: Regular eating pattern (3 meals + 2–3 snacks), exposure to fear foods.
  • Levels of Care: Outpatient → IOP → PHP → Residential → Inpatient (medical instability).

Recovery

Full recovery possible. Early intervention improves prognosis. Multidisciplinary team (therapist, dietitian, physician, psychiatrist) essential.

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