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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Bulimia nervosa and binge-eating disorder

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Purging with electrolyte or gastrointestinal danger

Collapse, arrhythmia, severe weakness, seizure, haematemesis, severe chest or abdominal pain, confusion, potassium below 2.5 mmol/L, severe dehydration or suicide risk require emergency assessment regardless of BMI.

Action: Assess ABCDE and glucose, obtain ECG, electrolytes including magnesium and phosphate, renal function and senior medical review, and treat the complication in an acute setting. Involve eating-disorder and mental-health services early; do not discharge after transient symptom relief without a plan for continued purging risk.

Synopsis

Distinguish bulimia nervosa from binge-eating disorder, identify concealed purging and acute complications at any weight, and use NICE psychological pathways with safe adjunctive prescribing.

  • A binge is an episode of eating with loss of control; quantity, context, speed, secrecy and subjective experience should be explored without moral language.
  • Bulimia nervosa includes recurrent binge eating with compensatory behaviour such as vomiting, fasting, excessive exercise or misuse of laxatives, diuretics or other treatment, alongside weight-shape overvaluation.
  • Binge-eating disorder has recurrent distressing binge episodes without the regular compensatory pattern that defines bulimia; weight loss is not the psychological-treatment target.
  • Both conditions occur across the weight range, and serious bulimia complications may be invisible during routine examination.
  • Check fluid and electrolytes when purging is suspected and use ECG according to rapid loss, severe purging, bradycardia, hypotension, electrolyte disturbance, exercise and medication risk.
  • For adults with binge-eating disorder, NICE offers focused guided self-help, followed by group CBT-ED if unacceptable or ineffective after 4 weeks; individual CBT-ED is an alternative when group treatment is unavailable or declined. Offer children and young people the same treatments, adapted to development.
  • For adult bulimia, consider focused guided self-help and, if unacceptable, contraindicated or ineffective after 4 weeks, individual CBT-ED. For children and young people, offer FT-BN first and consider individual CBT-ED if FT-BN is unacceptable, contraindicated or ineffective.
  • Fluoxetine 60 mg daily has a UK adult indication as a complement to psychotherapy for reducing bingeing and purging, but medication is not sole treatment and physical risk modifies prescribing.

    • Key red flags

    Syncope, palpitations, chest pain or muscle weakness after vomiting, laxatives or diuretics may indicate hypokalaemia or arrhythmia and needs urgent ECG and bloods.

    Haematemesis, sudden severe chest pain, surgical abdominal signs or subcutaneous emphysema raises concern for mucosal tear or gastrointestinal perforation.

    Seizure or confusion may follow severe sodium disturbance from water loading, dehydration or rapid electrolyte change.

    Insulin omission or underdosing for weight control risks diabetic ketoacidosis and requires immediate diabetes and eating-disorder expertise.

    Escalating binge-purge frequency, self-poisoning, suicidal intent or inability to interrupt behaviour needs same-day psychiatric and physical review.

    Investigation priorities

    01
    Behavioural eating assessmentFirst step

    Characterise binge experience, compensation, dietary restraint, triggers and weight-shape overvaluation.

    Management branches

    Initial presentationName the binge-purge pattern

    Loss-of-control eating, secretive episodes, vomiting or weight-control behaviours are reported or suspected.

    1. Ask non-judgementally about binges, every compensatory method, diet rules, triggers, impairment and the person's goals.
    2. Assess physical health, fluid and electrolyte risk, ECG indications, dental needs and current suicide or self-harm risk.
    3. Refer immediately to an age-appropriate eating-disorder service and provide clear emergency return advice.

    Key medicines

    FluoxetineFor adult bulimia nervosa, 60 mg orally once daily as a complement to psychotherapy; reassess benefit because efficacy beyond three months is not established.Not sole treatment; review suicidality, bipolarity, interactions, sodium, bleeding risk and seizure risk, and correct electrolyte or QT hazards before prescribing.
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    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG69 eating disorders recommendationsStepped psychological treatment and physical-risk assessment.
    • RCPsych CR233 Medical Emergencies in Eating DisordersPurging, electrolyte, gastrointestinal and emergency management.
    • Fluoxetine 60 mg capsules UK SmPCAdult bulimia indication, dose and duration evidence.
    • NHS eating disorders overviewCurrent descriptions and routes to care.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom