Skip to main content
    • Aa
    • Aa

Incidence and outcomes of bulimia nervosa: a nationwide population-based study

  • A. Keski-Rahkonen (a1) (a2) (a3), H. W. Hoek (a3) (a4) (a5), M. S. Linna (a1), A. Raevuori (a1) (a3), E. Sihvola (a1) (a2), C. M. Bulik (a6), A. Rissanen (a2) and J. Kaprio (a1) (a7) (a8)...

Little is known about the epidemiology of bulimia nervosa outside clinical settings. We report the incidence, prevalence and outcomes of bulimia nervosa using for the first time a nationwide study design.


To assess the incidence and natural course and outcomes of DSM-IV bulimia nervosa among women from the general population, women (n=2881) from the 1975–79 birth cohorts of Finnish twins were screened for lifetime eating disorders using a two-stage procedure consisting of a questionnaire screen and the Structured Clinical Interview for DSM-IV (SCID). Clinical recovery was defined as 1-year abstinence from bingeing and purging combined with a body mass index (BMI) ⩾19 kg/m2.


The lifetime prevalence of DSM-IV bulimia nervosa was 2.3%; 76% of the women suffered from its purging subtype and 24% from the non-purging subtype. The incidence rate of bulimia nervosa was 300/100000 person-years at the peak age of incidence, 16–20 years, and 150/100000 at 10–24 years. The 5-year clinical recovery rate was 55.0%. Less than a third of the cases had been detected by health-care professionals; detection did not influence outcome. After clinical recovery from bulimia nervosa, the mean levels of residual psychological symptoms gradually decreased over time but many women continued to experience significantly more body image problems and psychosomatic symptoms than never-ill women.


Few women with bulimia nervosa are recognized in health-care settings. Symptoms of bulimia are relatively long-standing, and recovery is gradual. Many clinically recovered women experience residual psychological symptoms after attaining abstinence from bingeing and purging.

Corresponding author
*Address for correspondence: Dr A. Keski-Rahkonen, Embaixada de Finlândia, SES Av. das Nações, Qd 807, Lt 7, CEP 70417-900, Brasília DF, Brasil. (Email:
Hide All
Becker AE, Grinspoon SK, Klibanski A, Herzog DB (1999). Eating disorders. New England Journal of Medicine 340, 10921098.
Berkman ND, Lohr KN, Bulik CM (2007). Outcomes of eating disorders: a systematic review of the literature. International Journal of Eating Disorders 40, 293309.
Bulik CM, Hebebrand J, Keski-Rahkonen A, Klump KL, Reichborn-Kjennerud T, Mazzeo SE, Wade TD (2007). Genetic epidemiology, endophenotypes, and eating disorder classification. International Journal of Eating Disorders 40 (Suppl.), S52S60.
Cullberg J, Engström-Lindberg M (1988). Prevalence and incidence of eating disorders in a suburban area. Acta Psychiatrica Scandinavica 78, 314319.
Currin L, Schmidt U, Treasure J, Jick H (2005). Time trends in eating disorder incidence. British Journal of Psychiatry 186, 132135.
Fairburn CG, Cooper Z (1993). The Eating Disorder Examination, 12th edn. In Binge Eating: Nature, Assessment and Treatment (ed. Fairburn C. G. and Wilson G. T.), pp. 317360. Guilford Press: New York.
Fairburn CG, Cooper Z, Doll HA, Norman P, O'Connor M (2000). The natural course of bulimia nervosa and binge eating disorder in young women. Archives of General Psychiatry 57, 659665.
Fairburn CG, Harrison PJ (2003). Eating disorders. Lancet 361, 407416.
Field AE, Herzog DB, Keller MB, West J, Nussbaum K, Colditz GA (1997). Distinguishing recovery from remission in a cohort of bulimic women: how should asymptomatic periods be described? Journal of Clinical Epidemiology 50, 13391345.
First MB, Spitzer RL, Gibbon M, Williams JBW (2003). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Nonpatient Edition. Biometrics Res., New York State Psychiatric Institute: New York.
Garfinkel PE, Lin E, Goering P, Spegg C, Goldbloom DS, Kennedy S, Kaplan AS, Woodside DB (1995). Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups. American Journal of Psychiatry 152, 10521058.
Garner DM (1991). Eating Disorder Inventory 2, Professional Manual. Psychological Assessment Resources, Inc.: Odessa, FL.
Hepworth N, Paxton SJ (2007). Pathways to help-seeking in bulimia nervosa and binge eating problems: a concept mapping approach. International Journal of Eating Disorders 40, 493504.
Hoek HW, Bartelds AI, Bosveld JJ, van der Graaf Y, Limpens VE, Maiwald M, Spaaij CJ (1995). Impact of urbanization on detection rates of eating disorders. American Journal of Psychiatry 152, 12721278.
Hoek HW, van Hoeken D (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders 34, 383396.
Hudson JI, Hiripi E, Pope HG Jr., Kessler RC (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 61, 348358.
Kaprio J, Pulkkinen L, Rose RJ (2002). Genetic and environmental factors in health-related behaviors: studies on Finnish twins and twin families. Twin Research 5, 366371.
Kaye WH, Greeno CG, Moss H, Fernstrom J, Fernstrom M, Lilenfeld LR, Weltzin TE, Mann JJ (1998). Alterations in serotonin activity and psychiatric symptoms after recovery from bulimia nervosa. Archives of General Psychiatry 55, 927935.
Keel PK, Mitchell JE (1997). Outcome in bulimia nervosa. American Journal of Psychiatry 154, 313321.
Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, Bulik CM, Kaprio J, Rissanen A (2007). Epidemiology and course of anorexia nervosa in the community. American Journal of Psychiatry 164, 12591265.
Keski-Rahkonen A, Sihvola E, Raevuori A, Kaukoranta J, Bulik CM, Hoek HW, Rissanen A, Kaprio J (2006). Reliability of self-reported eating disorders: optimizing population screening. International Journal of Eating Disorders 39, 754762.
Lehmann HE (1983). Clinical evaluation and natural course of depression. Journal of Clinical Psychiatry 44, 510.
Lewinsohn PM, Striegel-Moore RH, Seeley JR (2000). Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry 39, 12841292.
Milos G, Spindler A, Schnyder U, Martz J, Hoek HW, Willi J (2004). Incidence of severe anorexia nervosa in Switzerland: 40 years of development. International Journal of Eating Disorders 35, 250258.
Mond J, Hay P, Rodgers B, Owen C (2006). Self-recognition of disordered eating among women with bulimic-type eating disorders: a community-based study. International Journal of Eating Disorders 39, 747753.
Rosenberg M (1989). Society and the Adolescent Self-Image. Revised edition. Wesleyan University Press: Middletown, CT.
Schousboe K, Willemsen G, Kyvik KO, Mortensen J, Boomsma DI, Cornes BK, Davis CJ, Fagnani C, Hjelmborg J, Kaprio J, De Lange M, Luciano M, Martin NG, Pedersen N, Pietiläinen KH, Rissanen A, Saarni S, Sorensen TI, Van Baal GC, Harris JR (2003). Sex differences in heritability of BMI: a comparative study of results from twin studies in eight countries. Twin Research 6, 409421.
Soundy TJ, Lucas AR, Suman VJ, Melton LJ (1995). Bulimia nervosa in Rochester, Minnesota from 1980 to 1990. Psychological Medicine 25, 10651071.
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA (1983). Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press: Palo Alto, CA.
Sullivan PF, Bulik CM, Kendler KS (1998). The epidemiology and classification of bulimia nervosa. Psychological Medicine 28, 599610.
Sutandar-Pinnock K, Woodside DB, Carter JC, Olmsted MP, Kaplan AS (2003). Perfectionism in anorexia nervosa: a 6–24-month follow-up study. International Journal of Eating Disorders 33, 225229.
Van Son GE, van Hoeken D, Bartelds AI, van Furth EF, Hoek HW (2006). Time trends in the incidence of eating disorders: a primary care study in the Netherlands. International Journal of Eating Disorders 39, 565569.
Wade TD, Bergin JL, Tiggemann M, Bulik CM, Fairburn CG (2006). Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort. Australian and New Zealand Journal of Psychiatry 40, 121128.
Wade TD, Bulik CM, Kendler KS (2000). Reliability of lifetime history of bulimia nervosa. Comparison with major depression. British Journal of Psychiatry 177, 7276.
Walsh BT, Devlin MJ (1998). Eating disorders: progress and problems. Science 280, 13871390.
Wilfley DE, Bishop ME, Wilson GT, Agras WS (2007). Classification of eating disorders: toward DSM-V. International Journal of Eating Disorders 40 (Suppl. S), 123129.
Willi J, Giacometti G, Limacher B (1990). Update on the epidemiology of anorexia nervosa in a defined region of Switzerland. American Journal of Psychiatry 147, 15141517.
Williams RL (2000). A note on robust variance estimation for cluster-correlated data. Biometrics 56, 645646.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 9
Total number of PDF views: 113 *
Loading metrics...

Abstract views

Total abstract views: 558 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd October 2017. This data will be updated every 24 hours.