DSM-5: Bulimia Nervosa Criteria

by | Mar 12, 2024 | Bulimia | 0 comments

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If you think you may have an eating disorder it is important to seek advice from your GP or health professional. The information in this blog post is intended for information purposes only and is not a substitute for personalised clinical advice. 

Bulimia is a complex and serious eating disorder. It is characterised by recurrent episodes of binge eating, followed by compensatory behaviours aimed at preventing weight gain. People struggling with bulimia often face significant difficulties with self-esteem and body image.

If you reach out to a specialist service for help, the initial step might be a diagnostic assessment. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is one of the most widely used diagnostic manuals worldwide. This blog post will describe the DSM-5 diagnostic criteria for bulimia, assessment considerations and the role of diagnosis.

DSM 5 criteria for Bulimia Nervosa

The table summarises the DSM 5 diagnostic criteria for bulimia nervosa:

A. Recurrent episodes of binge eating, as characterised by both:
1. Eating, within any 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A feeling that one cannot stop eating or control what or how much one is eating.
B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours occur, on average, at least once a week for 3 months.
D. Self-evaluation is unjustifiably influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Current severity:
Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4–7 episodes of inappropriate compensatory behaviours per week.

Severe: An average of 8–13 episodes of inappropriate compensatory behaviours per week.

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviours per week.

A: Binge eating

The presence of binge-eating is the first criteria for Bulimia Nervosa. Binge-eating involves consuming very large amounts of food, usually much more than what would be considered “normal” for the circumstances, in a short period of time (2 hours of less). During these episodes, individuals feel a complete loss of control over their eating, unable to stop until the binge is over.

Binges can be categorised as objective or subjective. Objective binges occur when a person eats an objectively large amount of food. There is no definition of the volume of food because this will vary depending on the circumstances. For example, it is very common for people to over-eat at Christmas. But without a sense of it being disproportionate, or a sense of having lost control, this would not be considered a binge. An average binge for someone with bulimia is between 3000-4500kcals. 

Subjective binges occur when someone has a sense of having lost control over their eating, but the total amount of food eaten would not be considered abnormally large. This type of binge is common in people with anorexia, but also occurs in bulimia and binge-eating disorder.

Binges typically occur in the evening, though this is not the case for everyone. A common pattern is someone who heavily restricts their eating through-out the day but then binges before bed. The foods consumed during binges are typically rich in carbohydrates, as the body seeks to replenish blood sugar levels depleted by earlier restriction (e.g., cakes, biscuits, ice cream, bread, cereal).

B: Compensatory behaviours

The second criteria for diagnosing bulimia involves the use of compensatory behaviours to try to prevent weight gain. These behaviours are usually driven by extreme feelings of guilt, disgust, or fear that the binge will cause weight gain.

One of the most common compensatory behaviours is self-induced vomiting. Individuals induce vomiting shortly after binge-eating episodes in an attempt to get rid of the food consumed. It is surprisingly ineffective, removing at most between a third to half of the food eaten. Self-induced vomiting can lead to a host of physical complications, including electrolyte imbalances, damage to the throat, and eroding teeth.

People with bulimia may also misuse laxatives, diuretics or diet pills. All of these methods are ineffective and highly dangerous. For example, laxatives remove very little calories as they work on the lower bowel. However, they can cause bloating, gas, electrolyte imbalance, bleeding, problems with kidney function. They can also cause serious and permanent paralysis of the bowel leading to long-term dependency on laxatives.

People may also compensate for food eaten in binges by using excessive exercise or fasting. These behaviours contribute to keeping people stuck in a cycle of low blood sugar, binging, and compensatory behaviours.

C: Frequency and duration

Binge-eating and compensatory behaviours need to have occurred for at least once a week for a minimum of 3 months. It is common for people to have periods where their eating difficulty is better or worse. Therefore, clinicians will try to assess what is happening on average.

This cut-off may seem arbitrary to some. It is used to help prevent over-diagnosis. We know that many mental health difficulties are short-term and resolve on their own, without treatment. Having said that, early intervention in eating disorders is key. So, if you feel you have lost control over your eating, seek support from a health professional as soon as possible.

D: Self-evaluation

Self-evaluation is the process by which people assess their own worth, abilities, and characteristics. For a diagnosis of bulimia to be given, this process must be significantly disrupted by a focus on weight and shape.

In lay terms, this means that people with bulimia place a very high level of importance on their weight and/or body shape when they think about how they are doing as a person. It is important to say that this might be very uncomfortable to acknowledge for some people. For example, it’s common for people to say that they really value factors such as personality, charisma, or interests in other people. But feel their own weight or appearance outweighs these factors when they evaluate themselves.

E: Exclusion criteria

For all mental health diagnosis, it is important that the thoughts and behaviours observed are not better explained by another condition. In the case of bulimia, it is important to ascertain that episodes of binging and purging are not solely occurring during an episode of anorexia.

Contrary to popular belief, binging in anorexia is common. Binges in anorexia may be smaller, subjective, binges or they may be large objective binges. The clinician will assess whether the overall pattern of eating and weight is better explained by anorexia (e.g., significantly low weight) or bulimia.

F: Severity

The severity criteria for bulimia are not commonly used in the UK. However, the DSM-5 does define severity levels based on the number of inappropriate compensatory behaviours used per week. This can be mild (1-3), moderate (4-7), severe (8-13) or extreme (14 or more).

The severity levels give an indication of the level of impact on the person, but it is not comprehensive. Because of this, the severity level may be increased to reflect the presence of other symptoms (e.g., electrolyte disturbance, self-harm, distress).

Role of diagnosis

Diagnosis is often the first step towards getting help and recovering. In the UK a diagnosis can be used to provide access to specialist treatment services or therapy under private health care.

Many people find a diagnosis to be a validating experience, particularly as it is common for people to feel they are “not sick enough” to deserve help. Diagnosis can also provide a language to explain to other people (e.g., family, friends, employers) about what is going on for you.

However, it is crucial to recognise the limitations of diagnosis. The most important point to make is that a diagnosis is absolutely not necessary to receive therapy (even if service structures require it). Most therapies for eating disorders, including CBT, are transdiagnostic. This means that the therapy is created to address eating disorders of all types.

In fact, it is very common for people to transition between the eating disorder categories. You may begin with a diagnosis pf anorexia but then later develop bulimia. Or initially meet the criteria for binge-eating disorder and later meet the criteria for bulimia. You might also stop meeting the full criteria in different stages of bulimia recovery.

So many people transition between diagnostic categories that it brings into question the utility of viewing them as distinct and separate mental disorders. Has someone really recovered for binge-eating disorder only to develop bulimia? Or is it the same underlying distress, being expressed slightly differently at different times.

Despite these challenges, diagnosis might be a useful first step towards recovering from bulimia and repairing your relationship with food.  

If you’ve read this and think you might be struggling with bulimia, book a free consultation to work with us.


Welcome. I'm Dr Jenny Davis, a Clinical Psychologist with a special interest in eating disorders. I'm passionate about helping people recover and build a healthy relationship with food. 


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