348 Feeding and Eating Disorders
symptoms meet criteria for binge-eating disord er or other specified eating disorder. Diag-
nosis should be based on the current (i.e.,  past 3 months) clinical presentation.
Risk and Prognostic Factors 
Temperamental. Weight concerns, low self-esteem, de pressive symptoms, social anxi-
ety disorder, and overanxious d isorder of childhood are associated with increased risk for
the development of bulimia nervosa. 
Environmental. Internalization of a thin body ideal has been found to increase risk for
developing weight concerns, which in turn increase risk for the development of bulimia
nervosa. Individuals who experienced childhood  sexual or physical abuse are at increased
risk for developing bulimia nervosa. 
Genetic and physiological. Childhood obesity and early pubertal maturation increase
risk for bulimia nervosa. Familial transmission of bulimia ne rvosa may be present, as well
as genetic vulnerabilities for the disorder.
Course modifiers. Severity of psychiatric comorbidity predicts worse long-term outcome
of bulimia nervosa.
Culture-Related Diagnostic Issues
Bulimia nervosa has been reported to occur wi th roughly similar frequencies in most in-
dustrialized countries, including the United  States, Canada, many European countries,
Australia, Japan, New Zealand, and South Afri ca. In clinical studies of bulimia nervosa in
the United States, individuals presenting with  this disorder are pr imarily white. However,
the disorder also occurs in ot her ethnic groups and with prevalence comparable to esti-
mated prevalences observed in white samples.
Gender-Related Diagnostic Issues
Bulimia nervosa is far more common in females than in males. Males are especially under-