represented in treatment-seeking samples, for reasons that have not yet been systemati-
cally examined.
Diagnostic Markers
No specific diagnostic test for bulimia nerv osa currently exists. However, several labora-
tory abnormalities may occur as a conseque nce of purging and may increase diagnostic
certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which
can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric
acid through vomiting may prod uce a metabolic alkalosis (elevated serum bicarbonate),
and the frequent induction of diarrhea or de hydration through laxative and diuretic abuse
can cause metabolic acidosis. Some individual s with bulimia nervosa exhibit mildly ele-
vated levels of serum amylase, pr obably reflecting an increase in the salivary isoenzyme.
Physical examination usually yields no physical findings. However, inspection of the
mouth may reveal significant and permanent loss of dental enamel, especially from lin-
gual surfaces of the front teeth due to recurrent vomiting. These teeth may become
chipped and appear ragged and “moth-eaten.” There may also be an increased frequency
of dental caries. In some individuals, the salivary glands, particularly the parotid glands,
may become notably enlarged. Individuals who induce vomiting by manually stimulating
the gag reflex may develop calluses or scars on the dorsal surface of the hand from re-
peated contact with the teeth. Serious cardia c and skeletal myopathies have been reported
among individuals following repeated use of  syrup of ipecac to induce vomiting.