Bulimia nervosa is an eating disorder associated with binge eating, followed by behaviors like purging or excessive exercising to compensate for the binge. The condition is often treated with a combination of medication and therapy [1].

What is bulimia nervosa?

Bulimia nervosa is an eating disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). People with bulimia are fixated on their body shape and weight and they evaluate themselves based on physical appearance. As a result, they engage in episodes of binge eating, during which they feel a lack of control over their food intake [2].

After a binge, people with bulimia compensate to prevent weight gain. They may abuse laxatives, purge, or excessively exercise to attempt to rid the body of calories consumed during the binge [2]. If left untreated, bulimia nervosa can interfere significantly with daily life and lead to critical medical complications [1].

Types of Bulimia Nervosa

The DSM specifies two types of bulimia nervosa: purging and non-purging type. These are described in more detail below [2].

  • Purging type: A person who fulfills the criteria for the purging type of bulimia regularly engages in purging behaviors, which include self-induced vomiting, or misuse of laxatives, diuretics, or enemas.
  • Non-purging type: A person who demonstrates the non-purging type of bulimia does not regularly purge. Instead, they use compensatory behaviors like fasting or over-exercising to eliminate excess calories consumed during a binge.

Symptoms of bulimia nervosa

If a person has bulimia nervosa, they will display both physical and psychological or behavioral signs and symptoms of the eating disorder. Below, these symptoms are described in more detail.

Physical Symptoms of Bulimia

The purging behaviors associated with bulimia can lead to physical symptoms and side effects, including the symptoms below [3]:

  • Gastrointestinal problems like stomach cramps, acid reflux, or constipation
  • Dizziness or fainting
  • Sleep disturbances
  • Cuts along the finger joints due to self-induced vomiting
  • Dry skin and nails
  • Thinning hair
  • Dental problems, like tooth decay, cavities, discolored teeth, and tooth sensitivity from vomiting
  • Irregular menstrual periods
  • Cold hands and feet
  • Swelling of the salivary glands around the jaw
  • Concentration problems
  • Visible fluctuations in weight, although body weight typically remains within a normal range
  • Bloating

Psychological/Behavioral Signs

Beyond the physical toll on the body, bulimia is associated with behavioral and psychological changes, such as [3]:

  • Frequent trips to the bathroom after eating
  • Fixating on weight, dieting, and food
  • Showing discomfort or fear when eating in front of other people
  • Skipping meals or participating in fad diets
  • Following an excessive exercise regimen, even when sick or injured
  • Performing food rituals, such as cutting food into small pieces or only eating one food group
  • Spending a significant amount of time in front of the mirror, checking for perceived body flaws, or appearing extremely worried about weight and body shape
  • Withdrawing from social engagements and usual activities because most time is spent binging, purging, and following food rituals
  • Consuming large quantities of water or calorie-free beverages
  • Frequently using mints, mouthwash, or chewing gum to mask odors associated with vomiting

Complications of bulimia nervosa

Bulimia doesn’t just affect psychological functioning; it harms multiple systems in the body because of repeated binging and purging behaviors. When it is not treated or managed, bulimia increases the risk of the following health problems [1]:

  • Esophageal problems, including gastroesophageal reflux disease, tears in the esophagus, and a condition called Barrett’s esophagus, which can increase the risk of esophageal cancer
  • Coughing, sore throat, hoarse voice, and speech problems from vomiting
  • Irritable bowel syndrome and constipation
  • Cardiac arrhythmia
  • Erosion of the teeth
  • Increased risk of diabetes
  • Rectal prolapse
  • Pancreatitis

In addition to these physical health problems, bulimia nervosa is associated with other mental health disorders, including depression and personality disorders [1].

Diagnosing bulimia nervosa

A doctor or mental health clinician will diagnose bulimia nervosa using criteria in the DSM. Before making a diagnosis, a doctor will typically perform a physical examination to assess for common warning signs of bulimia, including bloating, abdominal pain, constipation, irregular menstrual cycles, and sore throat. A physician performing a diagnosis will also check a patient’s height, weight, vital signs, and blood pressure and check the skin and mouth for signs of bulimia [1].

Since bulimia nervosa is also associated with medical complications, a thorough evaluation during diagnosis will usually involve blood work to test electrolyte levels, liver functioning, and lab tests. Beyond performing these medical tests, a doctor will also rule out alternative diagnoses, such as neurological conditions, biliary disease, or binge eating disorder [1].

Ultimately, a bulimia nervosa diagnosis occurs when a patient meets the following criteria [2]:

  • Repeated episodes of binge eating, during which a person consumes larger amounts of food than a typical person would normally consume.
  • Loss of control over the amount of food consumed during binge episodes.
  • Repeated compensatory behaviors, such as fasting, diuretic abuse, laxative abuse, self-induced vomiting, or excessive exercise to compensate for calories consumed during a binge.
  • Binging and using compensatory behaviors at least once per week, on average, for three months.
  • A person evaluates themselves largely based on weight and body shape.
  • Behaviors associated with the eating disorder are not a symptom of anorexia.

Once a diagnosis is made, bulimia is classified as mild (1-3 episodes of binging/compensatory behaviors per week), moderate (4-7 episodes of binging/compensatory behaviors per week), or severe (8-13 episodes of binging/compensatory behaviors per week) [2].

Causes of bulimia nervosa

There is not one single cause of bulimia nervosa. Several risk factors can make a person more likely to develop this condition. Some common risk factors for bulimia are listed below [4]:

  • History of childhood sexual abuse
  • Being teased or bullied because of weight
  • Body dissatisfaction
  • Dieting behavior
  • Feeling pressure to be thin
  • Tendency to experience negative moods
  • Other mental health conditions like ADHD

Beyond these specific risk factors, research suggests that individuals with bulimia nervosa have abnormalities in the structure and function of the brain [1].

Prevention of bulimia nervosa

The best way to prevent bulimia nervosa is to intervene early when a person demonstrates risk factors. For example, a teen who is beginning to diet and is deeply concerned with weight and body shape may benefit from working with a counselor and/or a nutritionist to help them develop a healthier relationship with food and their body.

If you are concerned about your child, the behaviors you practice at home can reduce their risk of developing bulimia nervosa. For example, avoid making critical comments about your own body or pressuring your child to maintain a certain weight or body shape. If your child makes negative comments about their body, discloses they have been bullied, or seems to have extreme negative moods, they may be at higher risk for developing bulimia. You can help by talking with them and connecting them with a mental health professional to reduce the likelihood of developing an eating disorder like bulimia nervosa.

Treatment for bulimia nervosa

Medication and therapy are the first lines of treatment for bulimia nervosa, but working with a dietician is also essential for recovery. Learn more about these three treatment options below.

Medication

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat bulimia nervosa because they effectively reduce symptoms of the disorder. The SSRI medication fluoxetine is FDA-approved specifically for the treatment of bulimia nervosa. Other medications in this class, including citalopram and sertraline, may also be used to treat bulimia [1].

Some other medications that may be used to treat bulimia nervosa include [1]:

  • Trazodone
  • Monoamine oxidase inhibitors and tricyclic antidepressants, but only in cases that do not respond to other medications because of the risk of side effects
  • Topiramate, an anti-seizure medication that reduces binges but comes with side effects

Therapy

Cognitive-behavioral therapy (CBT) and interpersonal therapy are the most common therapeutic modalities used to treat bulimia nervosa [1]. CBT can help patients with bulimia to change unhelpful thinking patterns related to eating disorder behaviors. At the same time, interpersonal therapy aims to help people improve their personal relationships to reduce the symptoms of psychological disorders.

Research suggests that CBT specific to eating disorders is the most effective method for achieving remission among people with bulimia nervosa [5].

Diet & Nutrition

Medication and therapy can reduce some of the symptoms of bulimia, but it is also important for patients to work with a nutritionist to develop healthier eating patterns. A nutritionist is a critical part of an eating disorder treatment team, as they can provide nutrition counseling and help patients to correct any medical complications arising from inadequate nutrition [6].

Self-care for bulimia nervosa

If you live with bulimia nervosa, it’s important to seek treatment to manage the condition and reduce the risk of complications from binging and compensatory behaviors. Beyond seeking treatment, the following self-care strategies can improve your mental health:

  • Maintain an adequate diet. Bulimia nervosa often leads to a vicious cycle of restricting calories, which increases appetite and then leads to a binge. Over a period of time, a person becomes caught in a cycle of restricting, binging because of extreme hunger, and then restricting again to compensate [7]. You can stop this cycle by being intentional about following an adequate diet. Focus on eating three meals per day and obtaining adequate amounts of protein and other vital nutrients to prevent binging from excessive hunger.
  • Avoid social media. Experts believe social media usage can contribute to body image concerns and eating disorder pathology, especially when people follow health and wellness influencers. These accounts tend to post inaccurate information about weight loss and dieting, which can be distressing if you have an eating disorder [8]. Staying off of social media can be a form of self-care for bulimia.
  • Make time for hobbies that don’t center on weight and body. Eating disorders like bulimia can quickly become your primary focus. In recovery, it’s important to build other areas of your life. Spend time on interests or hobbies that bring you joy and have nothing to do with maintaining a certain body shape. For example, spend time on movement that brings you joy, such as a walk through nature or gentle stretching. Or, perhaps you have hobbies you enjoyed before the onset of your eating disorder. Return to spending time on these hobbies as you recover from bulimia nervosa.

Helping someone with bulimia nervosa

If a friend or a family member has bulimia nervosa, it’s important to be supportive and help them to find treatment. You can be supportive by learning about the symptoms of bulimia so you have a better understanding of what your loved one is experiencing. You can also show your support by talking with them in a helpful way.

Below are some things you should and shouldn’t say to someone with bulimia nervosa:

  • Don’t comment on their weight or body shape, even if they are positive. Discussing weight, even as a compliment, feeds the fixation on weight and dieting.
  • Do not discuss your weight or body image concerns in front of your loved one with bulimia.
  • Don’t make comments like, “You should just stop eating!” This invalidates the difficulty your loved one experiences with controlling binges.
  • Encourage your loved one to seek treatment and remind them there is no shame in asking for help.
  • Find opportunities to compliment your loved one in ways that have nothing to do with their weight. For example, praise them for their hard work or kindness toward others.

Frequently asked questions about bulimia

The answers to the following questions provide additional information about bulimia nervosa.

What’s the difference between anorexia and bulimia?

Both anorexia and bulimia are eating disorders, but there are differences between the two conditions. Bulimia involves a fixation on weight and body shape. People with this condition engage in binging behavior, followed by compensatory behaviors like vomiting or laxative misuse to compensate for binges.

On the other hand, individuals with anorexia nervosa have an intense fear of weight gain and restrict food intake so severely that they develop a significantly low body weight. While individuals with bulimia tend to be of normal body weight, those with anorexia tend to be significantly underweight and deny the severity of their low body weight. A person with anorexia may fall under the binge/purge subtype, meaning they have episodes of binging and purging, but they continue to restrict calories when not binging. As a result, they maintain a low body weight [2].

How common is bulimia nervosa?

Bulimia nervosa is not a common condition. According to prevalence data, around 0.9% of U.S. adolescents have bulimia nervosa. The prevalence is 1.5% among the general population of adult women and 0.5% among men. Across Europe, North America, and Australia, the prevalence among women ranges from 0.5% to 2.0%, and among men, it ranges from 0.1% to 1.3% [1].

How long does bulimia nervosa last?

For most people, bulimia is not a lifelong condition, and people do recover. For example, over a 5-year period, 74% of people with bulimia achieve remission [1].

Resources:

  1. Jain A, Yilanli M. Bulimia nervosa. (2022, August 1). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Retrieved October 21, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK562178/
  2. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. (2016 June). Substance Abuse and Mental Health Services Administration. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). Retrieved October 21, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t16/
  3. Bulimia nervosa. (n.d.) National Eating Disorders Association. Retrieved October 21, 2022, from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia
  4. Solmi, M., Radua, J., Stubbs, B., Ricca, V., Moretti, D., Busatta, D., Carvalho, A.F., Dragioti, E., Favaro, A., Monteleone, A.M., Shin, J., Fusar-Poli, P., & Castellini, G. (2021). Risk factors for eating disorders: An umbrella review of published meta-analyses. Brazilian Journal of Psychiatry, 43(3). https://doi.org/10.1590/1516-4446-2020-1099
  5. Slade, E., Keeney, E., Mavranezouli, I., Dias, S., Fou, L., Stockton, S., Saxon, L., Waller, G., Turner, , Serpell, L., Fairburn, C.G., & Kendall T. (2018). Treatments for bulimia nervosa: a network meta-analysis. Psychological Medicine, 48(16), 2629-2636. https://doi.org/10.1017/s0033291718001071
  6. Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders. (2006). Journal of the Academy of Nutrition and Dietetics, 106(12), 2073-2082. https://doi.org/10.1016/j.jada.2006.09.007
  7. Walsh, B.T. (2011). The importance of eating behavior in eating disorders. Physiology & Behavior, 104(4), 525-529. https://doi.org/10.1016/j.physbeh.2011.05.007
  8. Marks, R.J., De Foe, A., & Collet, J. (2020). The pursuit of wellness: Social media, body image and eating disorders. Children and Youth Services Review, 119, 105659. https://doi.org/10.1016/j.childyouth.2020.105659