People with bulimia nervosa 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 self-help measures. Many people with bulimia get better with treatment.
What is bulimia?
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.
Who develops bulimia nervosa?
Bulimia most commonly starts around the teenage years. It affects around 2 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 greater than in the general population.
Symptoms of bulimia
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.
Effects of 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 women with bulimia 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.
Causes of bulimia
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.
Chemicals called serotonin and dopamine found in some parts of the brain are thought possibly 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 changes in systems involving these chemicals.
Are there any tests done for bulimia nervosa?
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 specialist eating disorder unit. Members of the team may include psychiatrists, psychologists, nurses, dieticians and other professionals.
The types of treatments that may be offered include the following:
Help with eating
It is best if you have regular 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. You may also be asked to keep a diary of any purging behaviours.
This is not a matter of just getting on with it yourself. Your eating disorder clinic would recommend a specific programme, and support you through it.
Cognitive behavioural therapy (CBT) is the most commonly used 'talking' (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.
For young people under the age of 18 years, specifically bulimia-focused family therapy is often advised. The young person and their parent or carer have regular sessions with a therapist over several months. You work together to improve the problems with eating and purging. Again this takes around 20 sessions over about six months.
Medication is currently not recommended for bulimia as there is no evidence that it makes a difference. You may, however, need medication if you also have other illnesses such as depression.
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?
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 return 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 8 out of 10 people have recovered from bulimia. The evidence suggests that treatment is effective in many people.
It is very unusual to die from bulimia.
Further reading and references
The International Statistical Classification of Diseases and Related Health Problems, tenth revision - ICD-10; Eating Disorders Victoria, 2015
Classifying eating disorders - DSM-5: Diagnostic and Statistical Manual of Mental Disorders; Eating Disorders Victoria, 2016
The Authorized Bratman Orthorexia Self-Test; Orthorexia.com, 2017
Body Mass Index (BMI) charts for girls and boys age 2-18; Royal College of Paediatrics and Child Health and Dept of Health.
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