Bulimia Diagnostic Criteria

There are several criteria that need to be met in order to have a diagnosis of bulimia nervosa, including eating a large amount of food in less than two hours and excessive concern about body weight and shape.

In addition to symptoms, those suffering from bulimia nervosa also have accompanying feelings of distress, remorse, and self-loathing.

Patient and doctor

According to the DSM-5, the following are criteria to have a diagnosis of bulimia nervosa (BN) (1,2,3):

  • Eating a large amount of food in a small amount of time (less than two hours)—much more than what someone would eat under similar circumstances. This is called a binge eating episode. 
  • When binging, the person will report that they have no control over what and how much they eat
  • Practice recurrent, inappropriate, compensatory behaviors to prevent gaining weight, with examples including:
    • Self-induced vomiting.
    • Misuse of medications with the goal of compensating for food consumed. 
    • Excessive exercise. 
    • Fasting.
  • The binge eating and compensatory behaviors both occur, on average, at least once a week for three months.
  • Excessive concern about body weight and shape.
  • These behaviors do not occur exclusively during episodes of anorexia nervosa (AN).
  • The sequence of behavior consists of calorie restriction, binge eating, and self-induced vomiting (or a type of purging behavior). This behavioral pattern is called the restriction model.
  • Binge eating is not otherwise better explained by another medical disorder, for example an esophageal or digestive pathology.

Accompanied with these symptoms are feelings of distress, remorse, and self-loathing. The behaviors must cause considerable personal and interpersonal stress. The DSM-5 can further classify patients as being in partial or full remission, depending on the frequency of binge eating episodes and the natural waxing and waning pattern of the illness.

Bulimia is rated based on severity and frequency of symptoms:

  • Mild: An average of 1-3 episodes per week.
  • Moderate: An average of 4-7 episodes per week.
  • Severe: An average of 8-13 episodes per week.
  • Extreme: An average of 14 or more episodes per week.

Who Can Diagnose Bulimia Nervosa?

Only licensed health care professionals can formally diagnose someone with any psychiatric disorder. Giving someone this diagnosis will usually require several appointments to gain a full understanding of their history, symptoms, and behaviors. Some providers may also contact family members to gain another view point and more accurate history, as some patients tend to downplay their symptoms. 

Unfortunately, because of embarrassment or denial, some individuals may not readily disclose all of their symptoms to their provider, delaying a necessary diagnosis. When a person first seeks care, it can be very difficult to come to terms with the reality of their illness. Others may feel that they do not want to be a bother and burden their health care provider. It is important to be open, honest, and forthcoming with all symptoms, relapses, triggers, and emotions. Patients may be encouraged to keep a diary of symptoms to better assist their provider.

Qualified diagnostic providers include:

These are medical doctors who attended medical school and completed supervised residency training. They are licensed to prescribe medication and deliver psychotherapy. Family medicine and general practitioners, who also attend medical school, can make diagnoses, but will typically refer the patient to someone who is better trained to provide psychotherapy. 

These have doctorate degrees in psychology who provide counseling and psychotherapy. While they cannot prescribe medication, and are not medical doctors, they receive extensive training (5+ years) in how to evaluate and treat mental health disorders, and can be invaluable to someone’s recovery. Both psychiatrists and psychologists can continue their education with specialized fellowship training, and both are heavily involved in medical research to improve therapy methods for future generations.

Depending on their location within the United States, some can practice without the supervision of a psychiatrist. They attend nursing school and later receive specialized training in how to diagnose psychiatric disorders and prescribe medication. Depending on their experience and certification, they can provide psychotherapy.

Licensed professional counselors have either a masters or doctorate degree in counseling. They provide counseling and therapy, but cannot prescribe medication. As of 2020, LPCs can diagnose psychiatric disorders in 32 states, but not in the other 16 states, such as Indiana and Maine. These laws are subject to change in light of the mental health crisis. That being said, they are well versed in DSM-5 criteria, and can usually make an accurate diagnosis. They will frequently refer people to see psychiatrists (4). 

What Are Common Lab Tests to Evaluate for BN?

In addition to a full history and mental status exam, several labs and tests are ordered to fully assess the health of the individual. These include (1,3,5):

Height and weight, including their lifetime highest and lowest weights at adult height are measured. If patterns of weight fluctuation can be provided, this is highly useful for the provider.

General blood tests to evaluate blood sugar, A1c, and electrolytes including their sodium, potassium, magnesium, and phosphorus. This is called a comprehensive blood chemistry panel (CMP).

To assess anemias and vitamin deficiencies, the provider will order a complete blood count (CBC), and may also check his or her Vitamin D and B12 level. 

Enzymes such as lipase and amylase. This will help the provider rule out any underlying pancreatic or GI related illness that could be contributing to excessive vomiting and nausea.

Depending on the severity of an individual’s symptoms and labs, the provider may also order an EKG to assess the electrical health of their heart.

If there are concerns that a patient may have aspirated vomit or ruptured their esophagus, like in an emergency room setting, the ER doctor may order a chest x-ray or swallow study.

If someone has generalized swelling from prolonged, consistent vomiting or diuretic use, urine studies will also be ordered to assess kidney function.

Vitals signs such as blood pressure, heart rate, and body temperature will be recorded, as these can clue the provider to how dehydrated or nutrient deficient someone is.

If the patient appears to be in an altered state, the provider will almost always order a urine drug screen.

In individuals who can become pregnant, a urine pregnancy test should be performed.

Bulimia nervosa significantly increases the risk of developing osteoporosis, so a DEXA scan may be ordered to evaluate bone health.

Each situation is unique. The provider will use their medical experience to determine if other accessory labs and tests are required. For example, if an individual has significant tooth decay or dental abscesses from excessive vomiting, a maxillary/facial CT scan may be required with a dental referral.

What Is the Role of a Self-Assessment?

Some of the core treatment methods for treating BN include (1,3,5):

  • Cognitive-behavioral therapy (CBT)
  • Interpersonal psychotherapy (IPT)
  • If there are other underlying psychiatric disorders, dialectical behavioral therapy (DBT) can also be of use.
  • Nutritional rehabilitation counseling.
  • Family therapy.

While undergoing these types of therapy, performing frequent self-evaluations is critical to recovery. This allows an individual to measure their recovery, while quantitatively placing a number on their progress. The best self-assessment methods include the PHQ-ED, SCOFF, EAT, and ESP surveys.

The Patient Health Questionnaire (PHQ) contains a long list of specific symptoms that someone can experience with BN. Over time, this is an excellent way to determine which symptoms are resolving and which still cause considerable stress (1,3,6).

The SCOFF questionnaire is recommended by the USPSTF and is an acronym to assess feelings around control, food, and body image (3)

The Eating Disorder Screen for Primary Care (ESP) can be a valuable screening tool. The Eating Attitudes Test (EAT) is the most commonly used self-reporting instrument that allows an individual to track if symptoms bother them always, usually, often, something, rarely, or never. This generates a score that is highly informative to both the patient and provider (1).

Group of women

Is It Difficult to Overcome Bulimia Nervosa Without Additional Support?

As with any illness, addiction, or in times of grief, relying on a stable, loving community is invaluable to recovery. Times of increased distress are expected, which is when friends and family can step in to be accountability partners. Great caution should be taken, however, when choosing a community. In the world of eating disorders, there exist two types of communities (7,8):

  1. Those who will help you recover from bulimia nervosa.
  2. Those who reinforce disordered eating, especially on the internet.

It may feel wonderful initially to meet other people who struggle with BN and share stories, but often, people can fall into the trap where disordered eating is enabled, encouraged, and excused. 

Finding a firm but supportive health care team, mentors, and friend/family community has been clinically proven to improve relationships, future outlook, psychological/emotional/physical well-being, improved quality of life, and better adherence to treatments. Those with supportive communities have been shown to miss fewer appointments and have fewer episodes of relapse (9). 

Resources


  1. Engel, S., et al. (2021). Bulimia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis. Up To Date. Topic last updated May 10, 2021. Accessed May 23, 2022. 
  2. Jain A, Yilanli M. Bulimia Nervosa. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562178/
  3. Yager, Joel; et al. (2022). Eating disorders: Overview of epidemiology, clinical features, and diagnosis. Up To Date. Topic last updated: May 16, 2022. Accessed May 23, 2022. 
  4. Sydne Enlund, A. G. (n.d.). Licensed Professional Counselors Authority to diagnose postcard. Retrieved June 27, 2022, from https://www.ncsl.org/research/health/licensed-professional-counselors-authority-to-diagnose-postcard.aspx 
  5. Donald M Hilty, M. D. (2021, October 16). Bulimia nervosa. Practice Essentials, Background, Frequency. Retrieved June 27, 2022, from https://emedicine.medscape.com/article/286485-overview#a1 
  6. Striegel-Moore, R. H., Perrin, N., DeBar, L., Wilson, G. T., Rosselli, F., & Kraemer, H. C. (2010). Screening for binge eating disorders using the Patient Health Questionnaire in a community sample. The International journal of eating disorders, 43(4), 337–343. https://doi.org/10.1002/eat.20694
  7. Wang, T., Brede, M., Ianni, A., & Mentzakis, E. (n.d.). Social Interactions in online eating disorder communities: A network perspective. PLOS ONE. Retrieved June 27, 2022, from https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0200800 
  8. Aghazadeh, S. A. (2021). “Recovery warriors”: The National Eating Disorders Association’s online community and rhetorical vision. Public Relations Inquiry, 11(1), 103–119. https://doi.org/10.1177/2046147×211014083 
  9. Perez, M., Van Diest, A.K. & Cutts, S. Preliminary examination of a mentor-based program for eating disorders. J Eat Disord 2, 24 (2014). https://doi.org/10.1186/s40337-014-0024-0

Last Update | 11 - 14 - 2022

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