# 104 - 6B81 Bulimia nervosa

# 6B81 Bulimia nervosa

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders
weight, shape and size (e.g. preoccupation with the nose or skin), and are not accompanied by 
disturbance in eating behaviour or marked weight loss. Some individuals (primarily males) with 
body dysmorphic disorder exhibit muscle dysmorphia such that they are preoccupied about 
being insufficiently muscular or lean and, in response, may exhibit unusual eating behaviours 
(e.g. excessive protein consumption) or engage in excessive exercise (e.g. weightlifting). In these 
cases, behaviours related to diet and exercise are motivated by a desire to be more muscular rather 
than to attain or maintain a low body weight. However, if low body weight idealization is central 
to the clinical presentation, and body weight is sufficiently low, a diagnosis of anorexia nervosa 
instead of body dysmorphic disorder should be assigned.
Bulimia nervosa
Essential (required) features
• Frequent, recurrent episodes of binge eating (e.g. once a week or more over a period of at 
least 1 month) are required for diagnosis. Binge eating is defined as a discrete period of time 
(e.g. 2 hours) during which the individual experiences a loss of control over their eating 
behaviour, and eats notably more or differently than usual. Loss of control over eating may 
be described by the individual as feeling like they cannot stop or limit the amount or type 
of food eaten; having difficulty stopping eating once they have started; or giving up even 
trying to control their eating because they know they will end up overeating.
• The presentation is characterized by repeated inappropriate compensatory behaviours to 
prevent weight gain (e.g. once a week or more over a period of at least 1 month). The most 
common compensatory behaviour is self-induced vomiting, which typically occurs within 
an hour of binge eating. Other inappropriate compensatory behaviours include fasting or 
using diuretics to induce weight loss, using laxatives or enemas to reduce the absorption 
of food, omission of insulin doses in individuals with diabetes, and strenuous exercise to 
greatly increase energy expenditure.
• Excessive preoccupation with body weight or shape is apparent. Preoccupation with weight 
or shape, when not explicitly reported, may be manifested in behaviours such as repeatedly 
checking body weight using scales; repeatedly checking body shape using tape measures 
or reflection in mirrors; constantly monitoring the calorie content of food or searching for 
information on how to lose weight; or exhibiting extreme avoidant behaviours, such as 
refusal to have mirrors at home, avoidance of tight-fitting clothes, or refusal to know one’s 
weight or to purchase clothing with specified sizing.
• There is marked distress about the pattern of binge eating and inappropriate compensatory 
behaviour, or significant impairment in personal, family, social, educational, occupational 
or other important areas of functioning. During the early phases of the disorder, symptoms 
may be concealed and functioning maintained through significant additional effort.
• The symptoms do not meet the diagnostic requirements for anorexia nervosa.
6B81
Feeding and eating disorders | Bulimia nervosa

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Feeding and eating disorders
Additional clinical features
• Binge-eating episodes may be “objective”, in which the individual eats an amount of food 
that is larger than what most people would eat under similar circumstances, or “subjective”, 
which may involve eating amounts of food that might be objectively considered to be within 
normal limits but are subjectively experienced as large by the individual. In either case, the 
core feature of a binge-eating episode is the experience of loss of control over eating.
• Additional characteristics of binge-eating episodes may include eating much more rapidly 
than usual, eating until feeling uncomfortably full, eating large amounts of food when not 
feeling physically hungry, or eating alone because of embarrassment.
• Binge eating is typically experienced as very distressing. This is often manifested in 
negative emotions such as guilt, disgust or shame, which also typically negatively affect the 
individual’s self-evaluation.
• Bulimia nervosa may be associated with weight gain over time. However, individuals with 
bulimia nervosa may be of normal weight or even low weight (although not sufficiently 
low to meet the diagnostic requirements for anorexia nervosa). The diagnosis of bulimia 
nervosa is based on the presence of regular binge eating and inappropriate compensatory 
behaviours, regardless of overweight status.
Boundary with normality (threshold)
• Infrequent overeating or feasting during culturally sanctioned holidays or occasional 
celebrations should not be characterized as binge eating for the purpose of assigning a 
diagnosis of bulimia nervosa. Similarly, exercise qualifies as inappropriate compensatory 
behaviour only if it is unusually intensive or prolonged, or is carried out to the exclusion of 
other activities or in spite of fatigue, pain or injury.
Course features
• Like anorexia nervosa, bulimia nervosa most commonly has its onset during the period 
from adolescence to early adulthood (i.e. between the ages of 10 and 24 years), typically 
following a stressful life event. Onset prior to puberty or after the age of 40 years is 
relatively rare.
• Bulimia nervosa is characterized by a variable course that can manifest as persistent 
symptoms or intermittent episodes of remission and exacerbation. Outcome appears to be 
related to course, such that individuals whose symptoms remit for a period longer than 1 
year tend not to experience relapse of the disorder.
Feeding and eating disorders | Bulimia nervosa

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders
• Individuals with bulimia nervosa are at a significantly increased risk of substance use, 
suicidality and health complications (e.g. gastrointestinal problems) that can lead to 
premature death.
• Some individuals may cease purging or compensatory behaviours but continue to engage 
in binge eating. In this case, the diagnosis may be changed to binge-eating disorder if all 
diagnostic requirements are met.
• Stressful life events or a history of anorexia nervosa increase the likelihood of the onset 
of bulimia nervosa. A restricting pattern in anorexia nervosa may evolve over time into 
a pattern of binging and purging in bulimia nervosa. In such cases, the diagnosis may be 
changed to bulimia nervosa after 1 year during which body weight has not been sufficiently 
low to meet the diagnostic requirements of anorexia nervosa.
Developmental presentations
• Onset of bulimia nervosa typically occurs during or shortly after puberty. Young children 
do not commonly engage in binge eating due to a lack of access and control of 
food availability.
Culture-related features
• The prevalence of bulimia nervosa is higher in cultures characterized by an idealized thin 
body ideal. In addition, the prevalence of bulimia nervosa is increasing in countries that 
are industrializing and transitioning to more global and urbanized societies.
• The distribution of bulimia nervosa across cultural groups within a society can change 
over time. For example, in the United States, the incidence of the disorder appears to be 
decreasing among Euro-American females and increasing among ethnic minority groups – 
particularly Latin Americans and African Americans.
• Purging methods may be locally specific, such as the use of herbal purgatives in Asia and 
the Pacific region (e.g. seaweed and herbal teas in Japan; indigenous tea in Fiji), and justified 
with medicinal or other rationales that may obscure their pathological significance.
Sex- and/or gender-related features
• Bulimia nervosa is more prevalent among females.
• Males are less likely than females to engage in purging behaviours, and have a greater 
tendency to use excessive exercise or steroids as compensatory behaviours in response to 
binges. Males are also less likely to seek treatment.
Feeding and eating disorders | Bulimia nervosa