Bulimia nervosa, binge eating and sexual disorders

• Bulimia nervosa is a serious eating disorder in which a person recurrently binge-eats and then uses compensatory behaviours (vomiting, misuse of laxatives or diuretics, fasting, excessive exercise) to prevent weight gain, with self-worth unduly tied to body shape and weight, while body weight usually stays normal or above normal. ^[4]
• Binge eating disorder is recurrent binge eating without regular compensatory behaviour, with marked distress, and weight is commonly above the healthy range. ^[2][4]
• Psychotherapy is the foundation of treatment: eating-disorder-focused cognitive behavioural therapy (CBT-ED) is the gold standard and first-line treatment for bulimia nervosa, and NICE recommends guided self-help and (if needed) CBT-ED for adults and family therapy for young people. ^[1][4]
• Fluoxetine is the only medication approved by the United States Food and Drug Administration (FDA) for bulimia nervosa; the effective dose in trials is 60 mg/day, while 20 mg/day was no better than placebo. ^[4]
• Sexual disorders in this topic fall into two broad groups: sexual dysfunctions (pain/desire/arousal/orgasm, and related distress) and paraphilic disorders (intense, persistent atypical sexual interests that cause harm or distress); management is stepped, and (for paraphilic disorders) ranges from psychotherapy with SSRIs to antiandrogens and gonadotropin-releasing hormone (GnRH) agonists when risk is high. ^[5][6]

By the end of this page you should be able to:

1. State the diagnostic criteria for bulimia nervosa and binge eating disorder, and say how each differs from anorexia nervosa. ^[1][4]
2. Recognise the physical signs of purging (including Russell sign and dental erosion) and interpret the electrolyte pattern they produce. ^[3]
3. Outline evidence-based psychological treatment for bulimia nervosa and binge eating disorder, including CBT-ED, guided self-help, family-based treatment and CBT-E. ^[1][4]
4. State the place of fluoxetine in bulimia nervosa, including dose and the time at which it is added, and mention the approved drug for binge eating disorder. ^[4]
5. Classify sexual dysfunctions and paraphilic disorders, and choose the first-line management for each. ^[6][7]
6. Explain the WFSBP stepped pharmacological algorithm for paraphilic disorders and its evidence levels and durations. ^[5][6]
7. Outline prevention, screening, special-group considerations and prognosis for these conditions. ^[1][4]

Bulimia nervosa is defined by three features that occur together: recurrent episodes of binge eating; recurrent inappropriate compensatory behaviour to prevent weight gain (such as self-induced vomiting, misuse of laxatives, diuretics or diet pills, fasting or excessive exercise); and self-evaluation that is unduly influenced by body shape and weight. The binge eating and compensatory behaviour occur, on average, at least once a week for a minimum of three months. Crucially, body weight is usually normal or above normal, in contrast with anorexia nervosa, in which weight is significantly low. ^[4]

The word "bulimia" describes binge eating as a symptom. What makes it a disorder is the combination of loss of control around eating, the compensatory drive to undo it, and the distorted self-evaluation. Many affected people keep the behaviour hidden for years; the diagnosis is often made only when they present with unexplained electrolyte disturbance, dental erosion, or fatigue. ^[3][4]

Binge eating is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in similar circumstances, with a sense of lack of control over what or how much is eaten. Compensatory behaviour is any action taken specifically to counteract the feared weight gain. Self-induced vomiting is the best known; misuse of laxatives and diuretics is common and is not harmless, because these agents do not prevent calorie absorption and instead deplete fluid and electrolytes. ^[1][3]

Binge eating disorder shares the core binge with bulimia nervosa, but lacks the regular compensatory behaviours. It is characterised by recurrent episodes of binge eating associated with at least some of the following: eating much more rapidly than normal; eating until uncomfortably full; eating large amounts when not feeling physically hungry; eating alone because of feeling embarrassed by how much one is eating; and feeling disgusted, depressed or very guilty afterwards. The episodes are associated with significant distress. They must occur, on average, at least once a week for a minimum of three months. Weight is commonly above the healthy range. ^[4]

The absence of compensatory behaviour is the feature that separates binge eating disorder from bulimia nervosa, and it is the feature that explains why body weight tends to rise. The disorder is not simply "overeating"; it is an eating disorder with a recognisable cognitive and emotional pattern, and it carries medical risk through excess weight, metabolic disease and psychiatric comorbidity. ^[4]

A minority of patients present with binge eating or purging below the frequency threshold, or with mixed forms. NICE advises treating these with the approach for the eating disorder they most closely resemble. ^[1] In practice, purge-focused and binge-focused presentations that do not meet full criteria still warrant the same assessment and, often, the same psychological treatment.

Sexual dysfunctions are sexual complaints that are persistent and that cause clinically significant personal distress. They are classified by the phases of the sexual response rather than by aetiology, into problems of desire (low or absent sexual interest/desire), arousal (difficulty becoming or remaining aroused, including erectile dysfunction in men), orgasm (delay, infrequency or absence), and pain (genito-pelvic pain, dyspareunia, vaginismus). ^[7]

Both ICD and DSM recognise these conditions; the ICD-11 grounds the diagnosis on persisting difficulty and distress for at least several months, and DSM-5-TR (2022) has kept the categories essentially unchanged from DSM-5. The important principle is that the symptom must cause distress: a variant of function that does not trouble the person is not a disorder. Sexual dysfunctions are usually multifactorial, arising from biological, psychological, relational and iatrogenic causes, and they are heavily prevalent in psychiatric practice because many psychotropic drugs and illnesses affect sexual function. ^[5][7]

A paraphilia is an intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. A paraphilia becomes a paraphilic disorder only when it causes clinically significant distress or impairment, or when it involves non-consenting persons or persons unable to consent. ^[6]

DSM-5 lists eight named paraphilic disorders (with DSM-5-TR, 2022, keeping them unchanged): voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder and transvestic disorder. DSM-5 also allows "other specified" and "unspecified" paraphilic disorders (for example, arousal patterns involving corpses or animals). ICD-11 places paraphilic disorders in a separate "Paraphilic Disorders" grouping and names eight categories: voyeuristic disorder, exhibitionistic disorder, pedophilic disorder, coercive sexual sadism disorder, frotteuristic disorder, other paraphilic disorder involving non-consenting individuals, paraphilic disorder involving solitary behaviour or consenting individuals, and unspecified paraphilic disorder. ^[6]

The distinction between behaviour and disorder matters for law, ethics and treatment: a person may have an unusual sexual interest and never develop a disorder, whereas a disorder requires harm, distress or non-consent. This is why the ICD-11 note is clinically important: distress that is entirely due to moral disapproval of one's own impulses is not sufficient for the diagnosis. ^[5][6]

CSBD is an impulse-control disorder in ICD-11, not a paraphilic disorder. It is characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges, leading to repetitive sexual behaviour over an extended period (six months or more), with marked distress or significant impairment. Examples include preoccupation with sex to the point of neglecting health, relationships or duties; repeated unsuccessful efforts to control the behaviour; continuing despite adverse consequences; and continuing even when little satisfaction is gained. CSBD is not diagnosed when the difficulty is purely a matter of moral judgement or disapproval about sexuality. ^[5]

CSBD overlaps with but is distinct from paraphilic disorders. Paraphilic content (for example, paedophilic or coercive sadistic interests) can co-occur with compulsive sexual behaviour, in which case both conditions are considered, and treating the paraphilia takes priority where there is risk to others. ^[5][6]

Robust, comparable epidemiology for these disorders is difficult, because case definitions, thresholds and methods vary widely. The figures below are the best current open estimates.

• Bulimia nervosa. APA (4th edition practice guideline, 2023) quotes a United States lifetime prevalence of approximately 0.28% (0.80% for anorexia nervosa, 0.85% for binge eating disorder). ^[2]
• Binge eating disorder. Lifetime prevalence is quoted by the same APA source at approximately 0.85%. Both men and women are affected by binge eating disorder; APA reports a US lifetime prevalence of approximately 0.85%. ^[2]
• Paraphilic interests and disorders. Prevalence estimates of paraphilic arousal are much higher than estimates of disorder. In one German community survey (men aged 40 to 79), 62.4% reported at least one sexual arousal pattern linked to a paraphilia, but only 1.7% reported it as distressing. A Swedish population survey found 3.1% of respondents (aged 18 to 60) reported arousal from exposing themselves to a stranger and 8% from spying on others having sex. Estimates of clinically significant paraphilic disorder are far lower, and rigorous data are sparse. ^[6]
• Compulsive sexual behaviour disorder. Population estimates for CSBD itself (rather than subclinical compulsive sexual behaviour) are in the range of 3% to 6% in the general population, with most studies finding higher rates in men. ^[5]
• Sexual dysfunction. Prevalence estimates vary widely by definition and setting; an Indian narrative review of sexual dysfunction research quotes prevalence rates of 10% to 60% for male and female sexual dysfunction (including Dhat syndrome) depending on population and ascertainment. ^[7]

Risk factors are multifactorial and only partly modifiable:

• For bulimia and binge eating: adolescent or young-adult onset; female sex for bulimia (although men are increasingly recognised); perfectionism and overvaluation of shape and weight; low self-esteem; previous dieting and weight suppression; childhood adversity or trauma; comorbid depression, anxiety, obsessive-compulsive disorder and substance misuse; and family histories of eating disorder or mood disorder. ^[1][3]
• For sexual dysfunction: increasing age (erectile dysfunction rises with age and vascular disease, particularly diabetes and cardiovascular disease); depression and anxiety; medications (antidepressants, antipsychotics, antihypertensives, opioids, and others); relationship factors; chronic illness; and surgery or trauma. ^[7]
• For CSBD and paraphilic disorders: male sex; comorbid mood, anxiety, attention-deficit/hyperactivity, substance-use and personality disorders; childhood adversity (reported in up to 30% with CSBD); neurological disease and dopaminergic medication (for CSBD symptomatology); and, for CSBD, comorbidity with paraphilic interests. Family history of offending and early exposure to violent or child sexual abuse imagery are noted associations. ^[5][6]

The core mechanism is a self-perpetuating cycle: dietary restraint sets up hunger and a sense of deprivation; a trigger (emotional or situational) then leads to bingeing; fear of weight gain drives compensatory behaviour; and the (usually) unchanged weight reinforces the belief that control is necessary. Purging (through vomiting or misuse of laxatives or diuretics) then disrupts physiology through repeated fluid, electrolyte and acid-base shifts, as described below. Depression, anxiety and impulsivity commonly co-occur and maintain the cycle. ^[3][4]

Gastric function is also affected: refeeding and irregular eating can aggravate reflux, and chronic vomiting can lead to dental erosion and salivary gland enlargement. Bone risk in bulimia is usually less severe than in anorexia nervosa because weight is maintained, but repeated cycles still carry endocrine and metabolic cost. ^[3]

Binge eating disorder sits on the same spectrum of eating-disorder psychopathology, but without the compensatory drive. The pattern is thought to be maintained by dietary restriction, emotion dysregulation and reward-system overactivity in response to palatable food, together with negative self-evaluation after the binge. Unlike bulimia nervosa, the body is in energy surplus, so the principal physical risks come from obesity-related metabolic disease rather than from purging. ^[4]

Sexual function depends on vascular integrity, hormonal milieu, sensory innervation, psychological state and the relational context. Dysfunction arises when any of these fail. Erectile dysfunction shares risk factors with cardiovascular disease (diabetes, hypertension, dyslipidaemia, smoking) and can precede cardiac events by months to years. Paraphilic and compulsive sexual behaviours are understood (in ICD-11 terms) as disorders of impulse control and of sexual preference patterns, often arising from biopsychosocial factors, with comorbid mood, anxiety, attention-deficit/hyperactivity, substance-use and personality disorders being common. ^[5][7]

Bulimia nervosa. Patients rarely volunteer the diagnosis. Useful questions (asked privately, without judgement) include: "Do you sometimes feel out of control around food?", "Do you ever make yourself vomit or use water tablets or laxatives to control your weight?", "How much does your weight or shape affect how you feel about yourself?" Physical clues that patients may mention include swollen salivary glands, dental sensitivity or erosion, repeated sore throats, epigastric pain, bloating, constipation and fatigue. ^[1][3]

Binge eating disorder. The story is of repeated, distressing binge episodes in the absence of regular compensatory behaviour: eating rapidly, to discomfort, when not hungry, often alone, followed by shame. Patients may present with obesity-related symptoms, but the eating pattern is the diagnosis. ^[4]

Sexual history and examination. A sexual history should be taken without assumptions and in a confidential setting. Useful open questions are "Are you sexually active?", "Is sex comfortable?" and "Do you have any concerns about your sexual function?". The history is structured by desire, arousal, orgasm and pain, and by chronology (lifelong or acquired; one situation or all), context (medications, illness, relationship, life events) and distress. Paraphilic disorders are identified from the sexual history and risk assessment (fantasy content, urges, actions, distress, non-consent, legal issues). Assessment of CSBD focuses on the pattern, duration (at least six months), impairment and distress described above. ^[5][7]

Examination in bulimia nervosa is often surprisingly bland, and body weight may be normal. The specific signs to look for are:

• Russell sign: abrasions or calluses on the knuckles or back of the hand from repeated scraping against the teeth during self-induced vomiting. ^[3]
• Dental erosion: loss of enamel, particularly on the lingual surfaces of the upper teeth, and increased dental sensitivity. ^[1][3]
• Salivary gland enlargement: fullness of the parotid region ("chipmunk cheeks"). ^[3]
• Signs of dehydration and chemical irritation: sore throat, inflamed mouth, halitosis; peripheral oedema from laxative or diuretic misuse or refeeding. ^[3]
• General signs of eating disorder: low mood, anxiety, possible self-harm.

Examination in sexual disorder depends on the complaint (for example, a focused genitourinary examination for pain or orgasmic complaints, or a cardiovascular and neurological examination where erectile dysfunction or trauma is relevant). For paraphilic presentations the physical examination is mainly to rule out organic causes and to assess general health and cognitive status. ^[7]

Risk assessment in bulimia nervosa and binge eating disorder includes physical risk (weight, vital signs, dehydration, electrolyte disturbance), purging severity and frequency, suicidal risk, substance use, and the level of insight and support available. NICE (NG69) advises acute medical care for severe electrolyte imbalance, severe malnutrition, severe dehydration or incipient organ failure, irrespective of whether the person has a low or normal BMI. ^[1][3]

For sexual disorders, risk assessment must include risk of harm to others (especially children) in paraphilic presentations, risk of self-harm in distressed or ashamed patients, and medical red flags (for example, erectile dysfunction with chest pain on exertion). Where risk to others is present, safeguarding and legal frameworks take priority over confidentiality. ^[5][6]

Two differential questions matter: when a patient presents with disordered eating, which eating disorder is this; and when a patient presents with a sexual complaint, which domain is affected and what caused it.

There is no blood test that diagnoses bulimia nervosa, binge eating disorder, a sexual dysfunction or a paraphilic disorder. Investigations serve to quantify risk, detect complications, and exclude medical causes.

Management must be multidisciplinary (medical, psychological, and, where relevant, dietetic and social), patient-centred and culturally sensitive. The named guidelines used here are NICE guideline NG69 (published 23 May 2017, last updated 16 December 2020), the APA Practice Guideline for the Treatment of Patients With Eating Disorders (4th edition, 2023), and DSM-5-TR for diagnosis. ^[1][2][4]

• Psychological treatment is first-line. Eating-disorder-focused CBT (CBT-ED) is the gold standard and first-line psychotherapy for bulimia nervosa, recommended by the APA either alone or together with an SSRI. ^[4]
• NICE pathway. Explain that psychological treatments have a limited effect on body weight. Consider bulimia-nervosa-focused guided self-help (CBT self-help materials plus brief supportive sessions, typically 4 to 9 sessions of 20 minutes over 16 weeks). If guided self-help is unacceptable, contraindicated or ineffective after four weeks, consider individual CBT-ED: up to 20 sessions over 20 weeks, with twice-weekly sessions in the first phase, moving to addressing extreme dietary restraint, shape/weight concerns and bingeing in response to difficult thoughts, and (towards the end) spacing appointments and relapse prevention, involving significant others if appropriate. ^[1]
• CBT-E. Two versions of CBT-E (CBT-Ef, focused; CBT-Eb, broad) reduced symptom severity versus wait-list in bulimia nervosa in trials, with benefit maintained to 60-week follow-up. ^[4]
• Medication. Do not offer medication as the sole treatment for bulimia nervosa. Fluoxetine is the only FDA-approved medication for bulimia nervosa; trials found 60 mg/day more effective than placebo (20 mg/day was not), reducing weekly binge-eating and vomiting, depression, carbohydrate craving and pathologic eating attitudes. It is used with CBT or when there is minimal response to psychotherapy alone after six weeks. Fluoxetine combined with CBT is more effective than fluoxetine alone or placebo. Topiramate can reduce binge eating and purging but is limited by weight-loss-related side effects. ^[1][4]

NICE recommends bulimia-nervosa-focused family therapy (FT-BN) for children and young people with bulimia nervosa: typically 18 to 20 sessions over six months, including psychoeducation, collaboration between parents and the young person to establish regular eating and minimise compensatory behaviour, individual meetings with the young person, self-monitoring, and (later) age-appropriate independence and relapse prevention. If FT-BN is unacceptable, contraindicated or ineffective, consider individual CBT-ED (typically 18 sessions over six months, with up to four additional parent/carer sessions, focused on motivation, regular eating, formulation, monitoring, problem-solving and relapse prevention). ^[1]

• Psychological treatment. Explain that psychological treatments have a limited effect on body weight and that weight loss is not the therapy target. Offer binge-eating-disorder-focused guided self-help (CBT self-help, 4 to 9 supportive sessions of 20 minutes over 16 weeks). If guided self-help is unacceptable, contraindicated or ineffective after four weeks, offer group CBT-ED (typically 16 weekly 90-minute sessions over four months) or, if group therapy is unavailable or declined, individual CBT-ED (16 to 20 sessions with formulation, regular meals, cognitive restructuring, exposure, weekly monitoring and body-image work). ^[1][4]
• Medication. Medication should not be the sole treatment. The FDA-approved medication for binge eating disorder is lisdexamfetamine; trials found 50 mg/day and 70 mg/day more effective than 30 mg/day or placebo at reducing binge-eating frequency. The APA suggests adults with binge eating disorder who prefer medication or have not responded to psychotherapy alone should be treated with either lisdexamfetamine or an antidepressant. SSRIs (fluoxetine, sertraline) have mixed but sometimes positive evidence; topiramate reduces binge eating and weight but has limiting side effects. ^[4]
• Children and young people. Offer the same treatments as recommended for adults. ^[1]
• Weight management. If weight or metabolic risk needs attention, refer to obesity-management guidance; weight loss should not be attempted during active psychological treatment, because it may trigger binge eating. ^[1][4]

IPT is an evidence-based alternative or augmentation for both bulimia nervosa and binge eating disorder, with CBT being faster early on but IPT catching up by follow-up. IPT addresses interpersonal problem areas (role disputes, transitions, deficits, unresolved grief) that may maintain the eating disorder. ^[4]

Sexual dysfunctions are managed matched to cause, usually in a stepped, biopsychosocial model: psychoeducation, attention to medication and comorbidity, cognitive behavioural and couple-based therapies, pelvic-floor physical therapy for pain disorders, and, for genitourinary syndrome of menopause, low-dose local vaginal oestrogen with moisturisers and lubricants. ^[7]

• Erectile dysfunction treatment includes lifestyle change, review of medications and vascular risk, and PDE5 inhibitors (such as sildenafil and tadalafil) as pharmacological options; daily low-dose tadalafil (5 mg) has been reported to outperform on-demand dosing (10 mg) in one small study, though longer trials are needed. ^[7]
• Desire and arousal disorders are treated primarily with psychological therapy; medical options are reserved for appropriate cases (for example, bupropion for antidepressant-induced dysfunction, or hormonal treatment for menopausal cases in women).
• Orgasmic delay, especially with SSRIs, may be addressed by dose review or switching the antidepressant where safe.
• Pain disorders (entry pain, deep pain) are treated by identifying and treating the cause (infection, skin disease, pelvic-floor over-activity) and with pelvic-floor physical therapy; superficial (provoked) vestibulodynia may respond to topical lidocaine, physical therapy and, in specialist hands, surgery for refractory cases.
• Any sudden or persistent sexual symptom in the presence of chest pain, breathlessness, neurological symptoms, diabetes, or a medication change requires medical assessment rather than reassurance. ^[7]

Treatment aims to manage paraphilic urges, prevent offences, reduce distress and promote non-paraphilic sexual behaviour. It is based on impairment and risk of harm to others, with increasing levels of intervention. Psychotherapy (preferably CBT) is included at every level; written informed consent is required before antiandrogen or GnRH agonist treatment. ^[6]

SSRIs also suppress paraphilic sexual fantasies and behaviour with only minor side effects, which makes them a suitable first pharmacological step before antiandrogens. Antiandrogens (CPA, MPA) and GnRH agonists lower testosterone and reduce sexual drive; they are reserved for cases with real risk of harm because of the physical side effects (hot flushes, bone-density loss, erectile dysfunction, feminisation, metabolic changes). ^[5][6]

Psychoeducation and psychotherapy are first-choice and should always be conducted. SSRIs and naltrexone are the most relevant pharmacological treatments for CSBD. Where CSBD coexists with a paraphilic disorder, hormonal agents may be indicated (with priority given to the paraphilia and to risk management). Cases associated with chemsex, dopaminergic medication (for example, in Parkinson disease), or neurological disease require tailored management. ^[5]

Duration of treatment for paraphilic disorders: in moderate cases, continue at least two years; where there is significant risk of sexual violence, prolong for at least five years. Treatment may be reduced or stopped where there is no change in sexual interest despite treatment, or where (in the majority of cases) violent fantasies/behaviour recur months or years after stopping. ^[6]

The medical complications of bulimia nervosa are a direct consequence of purging rather than of starvation.

• Electrolyte disturbance. Vomiting, laxative and diuretic misuse produce hypokalaemia (potassium loss through renal and gastrointestinal routes), hyponatraemia (from dehydration or water-loading), hypochloraemia and metabolic alkalosis. Laxatives and diuretics do not reduce calorie absorption, so they do not cause weight loss; they mainly harm fluid and electrolyte balance. ^[1][3]
• Severe hypokalaemia can precipitate cardiac arrhythmia and requires urgent attention; unexplained electrolyte disturbance in a normal-weight young person should prompt direct enquiry about purging. ^[3]
• Russell sign: knuckle abrasions from self-induced vomiting. ^[3]
• Dental erosion (especially lingual surfaces of upper teeth), parotid hypertrophy (facial fullness), sore throat, and oesophageal/gastric irritation from repeated vomiting. ^[1][3]
• Bowel dependency on stimulant laxatives, with rebound constipation and fluid retention on withdrawal. ^[3]
• Cardiac effects of electrolyte imbalance (including QT changes) and of any medication (hence ECG monitoring is advised with drugs that can affect cardiac function). ^[1][3]
• Menstrual irregularity is common in bulimia nervosa and binge eating. ^[3]
• Refeeding risk applies when a severely purging patient is refed: phosphate, potassium and magnesium can fall during early refeeding. ^[1][3]

Complications are predominantly metabolic and cardiovascular: weight-related risk of type 2 diabetes, dyslipidaemia, hypertension, obstructive sleep apnoea and osteoarthritis, together with psychiatric comorbidity (depression, anxiety) and the psychosocial burden of shame and social withdrawal. ^[4]

Complications of untreated sexual dysfunction include relationship breakdown, depression, anxiety and, in men, an association with cardiovascular disease. Paraphilic disorders carry legal consequences, risk to victims and risk of suicide in distressed offenders. CSBD carries risk of relationship, occupational and financial harm; in men with paraphilic disorders and violence risk, the stakes are higher still. Psychotropic treatment (SSRIs in particular) commonly causes sexual side effects (desire, arousal and orgasm), which are a frequent reason for non-adherence and should be anticipated, monitored and managed. ^[5][6][7]

• Bulimia nervosa responds well to psychological treatment in many cases, but relapse is common and the course can be chronic; early, evidence-based treatment improves outcome. Medication alone is not curative. ^[1][4]
• Binge eating disorder is responsive to CBT and IPT; many patients remit, but rates vary, and obesity-related risk may persist even after bingeing stops. ^[4]
• Sexual dysfunction is usually treatable; most causes are identifiable and modifiable, although long-standing or trauma-related cases take longer. ^[7]
• Paraphilic disorders have a chronic course in many cases; longer treatment, consistent monitoring and a clear written plan (including duration of at least two years, or five years where there is violence risk) are needed, and risk never drops to zero simply because treatment has started. ^[6]

• Eating disorders. Early identification and referral matter. NICE advises that eating disorders can present at any age but risk is highest between 13 and 17 years; do not use screening tools alone to diagnose; refer immediately when an eating disorder is suspected; treat at the earliest opportunity. APA (4th ed., 2023) recommends screening for an eating disorder as part of an initial psychiatric evaluation. ^[1][2]
• Prevention. Reducing weight stigma; correcting myths about eating disorders; supporting non-restrictive, health-oriented eating in adolescents; and addressing comorbid depression, anxiety and trauma early. ^[1]
• Sexual health. Ask permission-giving questions routinely (for example, at postpartum, contraception, menopause, and before starting medications with sexual side effects); review medications before prescribing those likely to affect sexual function; treat sexually transmitted infections, genitourinary symptoms and pelvic-floor dysfunction early. ^[7]
• Paraphilic disorders and CSBD. Prevention focuses on risk assessment, safeguarding, early intervention for at-risk individuals (including those seeking help with paedophilic interests), and public-health approaches to child protection. Pharmacological treatment is offered when indicated and with consent; safeguarding takes precedence. ^[5][6]

Women with bulimia nervosa can conceive and may improve or worsen during pregnancy. NICE (NG69) advises advice and education when planning conception (adequate nutrient intake, healthy body weight, stopping binge eating, vomiting, laxatives and excessive exercise), nomination of a dedicated professional to monitor and support during pregnancy and the postnatal period, offering treatment as for the non-pregnant patient, and more intensive prenatal care where there is current or past anorexia nervosa. Pregnancy can mask purging-related electrolyte disturbance, so reassessment is needed. ^[1][3]

• Bulimia nervosa. FT-BN is the treatment of choice; individual CBT-ED is used if FT-BN fails or is not acceptable. ^[1]
• Binge eating disorder. The same treatments as for adults, offered in an age-appropriate way. ^[1]
• Sexual dysfunctions are less common in adolescents and usually psychosocial; experienced counsellors or adolescent services are often more appropriate than medical treatment. ^[7]
• Paraphilic behaviour in minors always requires child-protection assessment and specialist referral rather than isolated psychiatric treatment.

Sexual activity commonly continues into later life, and sexual complaints in older people are often attributed to age when they in fact reflect illness, medication or relationship factors. Eating-disorder presentations in older adults (including late-onset bulimia) do occur and are managed on the same principles, with heightened vigilance for medical comorbidity, polypharmacy and frailty. ^[3][7]

Men are increasingly recognised with binge eating disorder and are under-diagnosed with bulimia nervosa. Pornography and behaviours that are secret or solitary may dominate the clinical picture, and shame may delay presentation. Same principles of assessment and treatment apply; family-based treatment is used where applicable. ^[4]

When prescribing for a person with an eating disorder, account for the effects of malnutrition and compensatory behaviour on drug absorption and effectiveness, on cardiac risk (especially with prolongation of the QT interval) and on adherence. NICE (NG69) advises ECG monitoring for patients taking medication that could compromise cardiac functioning (including drugs that could cause electrolyte imbalance, bradycardia below 40 beats/min, hypokalaemia or prolonged QT). ^[1]

• Bulimia nervosa is binge eating plus regular compensatory behaviour (vomiting, laxative/diuretic misuse, fasting or excessive exercise) at least weekly for three months, with self-evaluation unduly tied to body shape and weight, usually at normal or above-normal weight. ^[4]
• Binge eating disorder is recurrent binge eating without regular compensatory behaviour, with marked distress, and weight commonly raised. ^[4]
• Purging harms mainly through fluid and electrolyte disturbance; hypokalaemia and metabolic alkalosis are common, and Russell sign (knuckle abrasions) is a classic physical sign. ^[3]
• Therapy is the treatment: CBT-ED is gold-standard first-line for bulimia nervosa; NICE offers guided self-help and CBT-ED for adults and family therapy for children and young people. ^[1][4]
• The same stepped approach applies to binge eating disorder: guided self-help, then group or individual CBT-ED; weight-loss should not be pursued during active treatment. ^[1][4]
• Fluoxetine is the only FDA-approved medication for bulimia nervosa; the effective dose is 60 mg/day (20 mg/day was no better than placebo); it is used with psychotherapy, not alone. ^[4]
• The approved drug for binge eating disorder is lisdexamfetamine (50 or 70 mg/day in trials); SSRIs and topiramate have supportive evidence. ^[4]
• Sexual dysfunctions (desire, arousal, orgasm, pain) require biopsychosocial assessment and matched treatment; distress is essential to the diagnosis. ^[7]
• Paraphilic disorder requires harm, distress or non-consent; DSM-5 lists eight named disorders, unchanged in DSM-5-TR (2022), and ICD-11 has eight categories. ^[6]
• CSBD (ICD-11) is a six-month or longer pattern of uncontrolled sexual behaviour with marked distress or impairment; SSRIs and naltrexone are the main pharmacological options. ^[5]
• The WFSBP algorithm for paraphilic disorders is stepped: psychotherapy always; SSRIs at level 2; antiandrogens (CPA or MPA) at level 3; GnRH agonists at level 4/5; minimum two years' treatment (five years if violence risk). ^[5][6]
• Prevention and screening for all of these conditions rest on early identification, destigmatised assessment and referral rather than on a single test. ^[1][7]

Eating-disorder service models, anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID, depression, anxiety, obsessive-compulsive disorder, female sexual dysfunction, erectile dysfunction, premature ejaculation, genitourinary syndrome of menopause, testosterone therapy, pedophilic disorder, eating disorders in pregnancy and diabetes (T1DE), cardiovascular disease and erectile dysfunction, Dhat syndrome. Cross-references are given in plain text because other topics are not yet all verified.