Bulimia Nervosa 347
self-esteem (Criterion D). Individuals with this disorder may closely resemble those with
anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the
level of dissatisfaction with their bodies. Ho wever, a diagnosis of bulimia nervosa should
not be given when the disturbance occurs only  during episodes of anorexia nervosa (Cri-
terion E).
Associated Features Supporting Diagnosis
Individuals with bulimia nervosa typically ar e within the normal weight or overweight
range (body mass index [BMI] ≥ 18.5 and < 30 in adults). The disorder occurs but is un-
common among obese individuals. Between eati ng binges, individuals with bulimia ner-
vosa typically restrict their to tal caloric consumption and preferentially select low-calorie
(“diet”) foods while avoiding foods that they pe rceive to be fattening or likely to trigger a
binge.
Menstrual irregularity or amenorrhea ofte n occurs among females with bulimia ner-
vosa; it is uncertain whether su ch disturbances are related to weight fluctuations, to nu-
tritional deficiencies, or to emotional dist ress. The fluid and electrolyte disturbances
resulting from the purging behavior are some times sufficiently severe to constitute med-
ically serious problems. Rare but potentially fatal complications include esophageal tears,
gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies have
been reported among individual s following repeated use of syrup of ipecac to induce vom-
iting. Individuals who chronically abuse laxatives may become dependent on their use to
stimulate bowel movements. Gastrointestin al symptoms are commonly associated with
bulimia nervosa, and rectal prolapse has also  been reported among individuals with this