People with bulimia nervosa (often just called bulimia) have episodes of binge eating. This is followed by deliberately making themselves sick (self-induced vomiting) or other measures to counteract the excessive food intake. Treatments include talking therapies, and sometimes medicines and self-help measures. Many people with bulimia get better with treatment.
What is bulimia nervosa?
Bulimia nervosa (often just called bulimia) is a condition where you think a lot about your body weight and shape. It affects your ability to have a 'normal' eating pattern.
Bulimia is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia nervosa, you are most likely to be normal weight or overweight. If you have anorexia you tend to eat less than you need to but if you have bulimia you have times when you "binge-eat". This is followed by times when you try to counteract the over-eating. This may be by vomiting, by not eating, by excessive exercise, or by misusing medicines. People with bulimia feel a loss of control over their excess eating.
How do I know if I have an eating disorder?
If you answer yes to two or more of these questions then you may have an eating disorder and you should see your doctor:
- Do you make yourself sick because you are uncomfortably full?
- Do you worry that you've lost control over how much you eat?
- Have you recently lost more than 6 kg (about one stone) in the previous three months?
- Do you believe you're fat when others think you're thin?
- Would you say that food dominates your life?
Who develops bulimia nervosa?
Bulimia mainly affects women aged 16-40. It most commonly starts around the age of 19 years. It affects around 1 in 100 women in the UK. Bulimia sometimes develops in men and children. Women are ten times more likely than men to develop bulimia. However, bulimia is becoming more common in boys and men. Bulimia is more common than anorexia nervosa.
There may be some genetic factor, as the risk of developing bulimia in close relatives of people with bulimia is four times greater than in the general population.
What are the symptoms of bulimia nervosa?
Bingeing and purging are the main symptoms and are usually done in secret.
- Bingeing means that you have repeated episodes of eating large amounts of foods and/or drinks. For example, you may eat a whole large tub of ice cream or two packets of biscuits even if you are not hungry. You feel out of control and unable to stop eating. Binge eating is often done very quickly until you feel physically uncomfortable. This happens not just on one occasion, but regularly. Eating patterns typically become chaotic.
- Purging means that you try to counteract the 'fattening' effects of the food from the bingeing. Making yourself sick (self-induced vomiting) after a bout of bingeing is the most well-known method. However, not all people with bulimia do this. Other purging methods include:
- Taking lots of laxatives.
- Extreme exercise.
- Extreme dieting or even periods of complete starvation.
- Taking 'water' tablets (diuretics).
- Taking other medicines such as amfetamines.
The reasons why you "binge-eat" and then purge may not be easy to explain. Part of the problem may be due to a fear of getting fat, although it is often not just as simple as that. All sorts of emotions, feelings and attitudes may contribute. The physical act of bingeing and purging may be a way of dealing with your emotions in some way.
What are the physical problems caused by bulimia?
These are caused by the unusual eating habits and the methods used to purge the body of food, such as being sick (vomiting) or the excessive use of laxatives. Physical problems do not always develop. They are more likely if you binge and purge often. One or more of the following may develop:
Many people have irregular periods, as hormone levels can be affected by poor diet. Periods may even stop altogether or you may find that your periods have never started, especially if you started having eating problems when you were younger.
Chemical imbalances in the body
These are caused by either repeated vomiting or excess use of laxatives. For example, a low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to muscle spasms (tetany).
These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes tummy (abdominal) pains.
Swelling of hands, feet and face
This is usually due to fluid disturbances in the body. The saliva glands in the face can sometimes swell due to the frequent vomiting.
These can be caused by the acid from the stomach rotting away the enamel as a result of repeated vomiting.
It is fairly common to feel low when you have bulimia. Some people even become depressed, which can respond well to treatment. It is important to talk about any symptoms of depression you may have. Many people find they become more moody or irritable.
These are very common and include feelings of guilt and disgust after bingeing and purging. Poor self-esteem, and mood swings, are common.
What causes bulimia nervosa?
The exact cause is not clear. Some people blame the media and the fashion industry which portray the idea that it is fashionable to be slim. This can put pressure on some people to try to be slim which can then lead to an eating disorder.
There may be some genetic factor to developing bulimia, which is triggered by stressful or traumatic life experiences. For example, some people with bulimia have had a childhood where there were frequent family problems with arguments and criticism at home. Some people with bulimia have been abused as a child.
Sometimes bulimia is also associated with some other psychological problem. (That is, the bulimia is sometimes just a part of a broader mental health problem.) For example, there is a higher-than-average rate of bulimia in people with anxiety disorders, obsessive-compulsive disorder, depression, post-traumatic stress disorder and some personality disorders.
A chemical called serotonin found in some parts of the brain is thought to have something to do with bulimia. In some way one or more of the above factors, or even other unknown factors, may lead to a low level of serotonin. This may be why antidepressants which restore serotonin levels are effective.
Are there any tests done for bulimia?
Although there is not an actual test to diagnose bulimia, your doctor may wish to undertake some blood tests. These are usually done to check your kidney function and potassium levels. This is in case these have been affected by behaviours such as repeatedly being sick (vomiting) or excessive laxative use.
What are the treatments for bulimia nervosa?
The aim of treatment is to:
- Reduce risk of harm which can be caused by bulimia.
- Encourage healthy eating.
- Reduce other related symptoms and problems.
- Help people become both physically and mentally stronger.
Most people with bulimia who see their GP will be referred to a specialised eating disorder unit. Members of the team may include psychiatrists, psychologists, nurses, dieticians and other professionals.
The sort of treatments that may be offered include the following:
Help with eating
It is best if you have regular meals, even if you only eat small meals. It is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other people) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary in order to write down all the food that you eat.
There are a number of self-help books and manuals available. These provide strategies in how to cope with, and overcome, bulimia. Some people find these very helpful and prefer them to "formal" treatment. It is certainly worth trying a self-help manual if there is a waiting list or difficulty in obtaining psychological treatment. Your health professionals may suggest a particular self-help strategy and provide back-up support.
Psychological ('talking') treatments
Cognitive behavioural therapy (CBT) is the most commonly used psychological treatment for bulimia. It helps you to look at the reasons why you developed bulimia. CBT aims to change any false beliefs that you have about your weight and body. It also helps to show you how to deal with emotional issues. Talking treatments take time and usually require regular sessions over several months.
However, CBT does not suit everyone. About a third of people drop out before finishing the course. Other forms of psychological therapies, either in groups, on an individual basis or using computer-based packages, may also be used.
A medicine may be advised by your doctor. The most commonly used medicines are selective serotonin reuptake inhibitor (SSRI) antidepressants. These are used to treat depression but, in higher doses, one called fluoxetine can reduce the urge for bingeing or purging. These are not usually recommended if you are younger than 18.
Treatment of any physical or teeth problems that may occur
This may include:
- Regular blood tests and taking potassium supplements where needed.
- Dental care: regular check-ups with the dentist.
- Help with cutting down use of laxatives.
What is the outlook (prognosis)?
Bulimia can usually be successfully treated. Treatment tends to be successful in more cases of bulimia than anorexia. Many people improve with treatment. However, bad spells (relapses) may recur from time to time in some cases. Many people find they still have issues with food, even after treatment. However, they are more in control and can lead happier, more fulfilled lives.
Studies suggest that after 10 years as many as 7 out of 10 people have recovered from bulimia. 3 out of 10 people continue to have problems. The evidence suggests that treatment (either talking treatments or antidepressants) is effective in many people.
It is very unusual to die from bulimia.
Further help & information
Further reading & references
- Eating disorders - core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders; NICE (January 2004)
- Eating disorders; NICE CKS, October 2014 (UK access only)
- Fairburn CG, Cooper Z, Doll HA, et al; Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up. Am J Psychiatry. 2008 Dec 15.
- Hay PP, Bacaltchuk J, Stefano S, et al; Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD000562. doi: 10.1002/14651858.CD000562.pub3.
- Anorexia and Bulimia; Royal College of Psychiatrists
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Mary Harding
Prof Cathy Jackson