ICD-116B81	BULIMIA NERVOSA Bulimia Nervosa
ICD-10F50.2	Bulimia nervosa
DSM-5-TRF50.2	Bulimia Nervosa

1. Definition and nosology

Bulimia Nervosa (ICD-11: 6B81; DSM-5-TR: F50.2) — an eating disorder characterized by recurrent episodes of binge eating (large amount of food in a short period + sense of loss of control) and compensatory behaviors (vomiting, laxatives, exercise, fasting). Unlike anorexia, weight is typically normal or overweight.

2. History

• Russell G.F. (1979) — term ‘bulimia nervosa’ and first clinical description.
• DSM-III (1980) — Official diagnosis.
• DSM-5 (2013) — frequency criterion reduced to once per week (2 times in DSM-IV).

3. Epidemiology

• Lifetime prevalence: in females 1.5–3%, in males 0.5%.
• Onset: adolescence and early adulthood.
• Comorbidity: MDD ~70%, anxiety, substance use, BPD, history of anorexia.
• Suicide risk high.

4. Aetiology and pathogenesis

• Heritability 50–60%.
• Neurobiological — serotonergic dysregulation, dopamine reward system.
• Social-cultural — thinness ideal, dietary history.
• Personality — impulsivity, perfectionism, low self-esteem.

5. Clinical features

• Binge eating episodes — loss of control, secretive.
• Compensatory behaviors:
  • Purging — self-induced vomiting, laxatives, diuretics;
  • Non-purging — fasting, excessive exercise.
• Body image and weight preoccupation.
• Medical complications: hypokalemia (vomiting), Russell's sign (calluses on fingers), dental erosion, parotid hypertrophy, esophagitis, gastrointestinal issues.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Repeated binge eating episodes — large amount of food in short period (≤ 2 hours) + feeling of loss of control.

B. Recurrent inappropriate compensatory behaviors to prevent weight gain.

C. Frequency: at least once weekly — DSM-5-TR requires ≥ 3 months, ICD-11 ≥ 1 month.

D. Self-evaluation and excessive dependence on body shape.

E. Does not occur in the context of an anorexia nervosa episode.

6.2 Source-specific clarifications

• DSM-5-TR — severity based on episode frequency (mild 1–3, moderate 4–7, severe 8–13, extreme ≥14 per week).
• ICD-11 — criteria overlap, but the required duration differs: ICD-11 requires at least 1 month, DSM-5-TR 3 months; ‘atypical bulimia nervosa’ qualifier.
• NICE NG69 — diagnosis and treatment.

6.3 Diagnostic algorithm

1. Clinical interview.
2. EDE-Q, EDE.
3. Medical: electrolytes (K, P, Mg, Cl), liver, kidney, EKG (QTc).
4. Dental examination (erosion).
5. Comorbidity and suicide risk.

6.4 Differential diagnosis

7. Examination and assessment

• EDE-Q.
• Medical: electrolytes, EKG, dental examination.
• C-SSRS.

8. Treatment

1. CBT-E first-line (Fairburn) — 20 sessions over 20 weeks; evidence: Fairburn C.G. et al. Am J Psychiatry 2009;166(3):311–319.
2. Fluoxetine 60 mg/day — FDA approval for BN; reduces binge eating and purging.
3. FBT (Lock J., Le Grange D.) — in adolescents.
4. IPT alternative.
5. Medical: electrolyte correction, refeeding, dental care.
6. Bupropion is contraindicated (seizure risk).

Source-specific specifications

• NICE NG69 — CBT-E first-line; FBT in adolescents.
• APA 2023.

Treatment methods

1. CBT-E (Fairburn) — 20 sessions; transdiagnostic; disruption of binge-purge cycle.
2. Fluoxetine 60 mg — FDA approval; reduces binge eating frequency by ~50%.
3. FBT for BN — Adapted for adolescents.
4. Interpersonal Therapy (IPT) — Alternative; slow response, but sustained effect.

9. Prognosis

• 50–70% remission with CBT-E; long-term follow-up is essential.

10. Myths and misconceptions

Myth 1: “Bulimia is a ‘diet failure’”

Evidence: Clinical impairment; restrictive diet is a typical trigger.

Myth 2: “Vomiting is an effective weight loss method”

Evidence: Vomiting prevents only 30–50% of calorie absorption; serious medical complications.

Myth 3: “Bupropion can be used as an antidepressant in BN”

Evidence: bupropion in BN is contraindicated — seizure risk is high.

Myth 4: “BN is not a problem if weight is normal”

Evidence: Medical complications (electrolytic, cardiac) and psychiatric burden are significant.

Myth 5: “Only antidepressants are sufficient”

Evidence: CBT-E + pharmacotherapy combination superior.

11. Sources

1. WHO. ICD-11. 6B81 Bulimia Nervosa. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE NG69. 2017/2020.
4. APA. Practice Guideline for Eating Disorders, 4th ed. 2023.
5. Fairburn C.G. Cognitive Behavior Therapy and Eating Disorders. Guilford Press; 2008.
6. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979;9(3):429–448.
7. Lock J., Le Grange D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. 2nd ed. New York: Guilford Press, 2013.