What Is Bulimia Nervosa?

An eating disorder characterized by binging and purging

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Bulimia nervosa (BN), commonly referred to as bulimia, is an eating disorder characterized by recurring binge eating episodes followed by purging behaviors, such as self-induced vomiting, fasting, misusing and abusing laxatives or diuretics, and extreme exercising, to prevent weight gain. According to the National Institute on Mental Health, it affects 0.3% of the population, and is five times more common in women than in men.

When a person binge eats, they consume an excessive amount of food in a short period of time rapidly and feel a lack of control over their eating. It is not the same as eating a larger meal than usual during occasions like holidays. People engaged in binge eating tend to choose comfort food that is sweet, salty, soft, or smooth, and high in calories. This eating disorder can be chronic or only occur only during times of stress.

Woman eating pizza and drinking wine in front of the refrigerator during the night

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Symptoms

Someone with bulimia may be thin, overweight, or of a normal weight. It can be difficult to tell if someone has bulimia because binging and purging are often done in private. Family or friends may see empty food wrappers in unexpected places or vomit in the home, which can signal that someone they know has bulimia.

Symptoms of bulimia often result from purging behaviors and will differ depending on the mode and frequency of purging. Repeat vomiting can cause stomach acids to dissolve protective tooth enamel, making teeth much more vulnerable to decay, while overuse of laxatives can cause chronic gastrointestinal problems.

The primary symptoms of bulimia include:

  • Swollen cheeks or jaw area
  • Calluses or scrapes on the knuckles (if someone is using their fingers to induce vomiting)
  • Teeth that look clear instead of white and are increasingly sensitive and decaying
  • Broken blood vessels in the eyes
  • Acid reflux, constipation, and other gastrointestinal problems
  • Severe dehydration
  • Irregular heartbeat (cardiac arrhythmias)
  • Low blood pressure (hypotension)

People with bulimia may also exhibit the following behavioral changes:

  • Extreme concern about body weight
  • Often going to the bathroom right after eating
  • Exercising a lot, even in bad weather or when hurt or tired
  • Acting moody or sad, hating the way they look, or feeling hopeless
  • Having problems expressing anger
  • Not wanting to go out with friends or do activities they once enjoyed

Causes

Bulimia usually begins with dieting, but gradually progresses toward extreme and unhealthy weight control methods. But dieting alone does not cause the condition. 

The cause of bulimia and other eating disorders is largely unknown, but researchers hypothesize that it is likely due to a combination of biological factors and life events.

Contributing factors related to bulimia include:

  • Activities in which leanness is emphasized (e.g., ballet, running, or wrestling) and sports in which scoring is partly subjective (e.g., skating and gymnastics)
  • Body image dissatisfaction and preoccupation 
  • Family history of eating disorder or another mental disorder
  • Genetics 
  • Growing up in an environment plagued by stress, poor patterns of communication, and unrealistically high expectations
  • Personal history of mental disorder (e.g., anxiety, panic disorder, obsessive compulsive disorder, and alcohol and drug abuse problems)
  • Weight stigma and internalized body ideals

Diagnosis

Bulimia is diagnosed using the following criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5):

  • Recurrent episodes of binge eating, as characterized by eating, within any two-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances and a feeling that one cannot stop eating or control what or how much one is eating
  • Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise
  • The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for three months
  • Self-evaluation is influenced by body shape and weight
  • The disturbance does not occur exclusively during episodes of anorexia nervosa

A doctor will also specify whether someone is in partial or full remission, with full remission being assigned when none of the criteria are met for a sustained period of time. Partial remission is defined as not all of the criteria have been met for a sustained period of time after full criteria for bulimia nervosa were previously met.

Your doctor may also use a screening tool called the SCOFF questionnaire to determine whether you have bulimia:

  • Do you make yourself sick because you feel uncomfortably full?
  • Do you worry you have lost control over how much you eat?
  • Have you recently lost more than one stone (14 lb) in a three-month period?
  • Do you believe yourself to be fat when others say you are too thin?
  • Would you say that food dominates your life?

One point is given to each question answered yes, and a score of two or more indicates someone may have anorexia or bulimia.

Your doctor may also perform blood or urine tests to rule out other possible causes of your symptoms. They may do other tests to see whether you have any other health problems caused by bulimia, including kidney function tests, electrolytes, or an electrocardiogram to see whether repeat binging and purging has affected your health.

There is a spectrum of severity for this diagnosis based on the number of inappropriate compensatory behaviors per week in the DSM-5. A mild case includes one to three behaviors, moderate four to seven, severe eight to 13, and anything over 14 is considered extreme. A mild diagnosis is still serious and requires treatment. 

Treatment

Like other eating disorders, a multidisciplinary approach to treatment is the most effective. Your clinician can offer advice on which options may be most appropriate.

Purging can cause life-threatening electrolyte imbalances, so some people with bulimia who purge regularly may need to be hospitalized if they have serious heart or kidney problems.

Psychotherapy

Cognitive behavioral therapy (CBT) can help an individual with bulimia improve their body image, understand and deal with emotions, modify obsessive thinking and compulsive behaviors related to food, and create healthy eating behaviors. Family and group psychotherapy can also be helpful.. Research has shown that CBT is the leading evidence-based treatment for bulimia.

Nutrition Counseling

A registered dietician can help people with bulimia develop a structured meal plan, stabilize weight and nutrition, and help decrease the cycles of binging and compensation.

Medications

Prozac (fluoxetine) is the only medication approved by the Food and Drug Administration for the treatment of bulimia, but only for adults. It can significantly reduce binging and purging, both on its own and in conjunction with other forms of treatment. It has also been shown to be effective at prevent relapse.

Selective serotonin reuptake inhibitors (SSRIs) may be beneficial in decreasing the frequency of binge eating and purging in people with bulimia. They may be considered for patients who are not responding to psychotherapy and those who have major depression or another comorbid disorder responsive to antidepressant medications. Sometimes other medications such as topiramate (Topamax) are used off-label for this disorder.

If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237

For more mental health resources, see our National Helpline Database.

Prognosis

Prognosis depends on the treatment approach and severity of the disorder. Relapse after treatment is not uncommon, but should not be seen as failure to recover. With sustained efforts, remission is possible. Some research has shown that approximately half of all people with bulimia will fully recover with the appropriate treatment, another 30% will experience a partial recovery, and 10% to 20% will continue having symptoms.

It's important to note, though, that bulimia can affect a person's chances of getting pregnant and cause problems during pregnancy. Repeat purging and binging can make the menstrual cycle irregular or period may stop for several months. Irregular or missing periods mean someone may not ovulate every month, which can make it difficult to get pregnant. Bulimia is also linked to an increased risk of miscarriages.

Coping 

Besides treatment, there are coping techniques that bulimia patients can use to stay on the path of their recovery, including practicing urge delays and alternatives to purging to disrupt the cycle of binging and purging. 

Join a support group where you can talk to others who have had similar experiences. The National Alliance on Mental Illness runs free, peer-led support groups for people who have a mental disorder, and you can find one in your local area through the organization's online directory.

Other coping strategies include:

  • Keep a food and mood diary: Writing can help identify and keep track of triggers and control binge eating impulses.
  • Practice mindfulness: Increase awareness of triggers and practice self-control and self-acceptance through meditation and yoga.
  • Support: Finding someone to talk to online, at a support group, a friend, family member, or significant other can help you feel more connected and motivated to continue with treatment.
  • Exercise: Moderate exercise can help improve your body image, boost mood through the release of endorphins (feel-good chemicals), and reduce stress and anxiety.
  • Sleep: Lack of sleep is linked to irregular eating patterns. Get seven to eight hours of sleep per night.

A Word From Verywell 

Reaching out when you feel like you have lost control is scary, but you have more power than you think. You are in control of whether or not you seek help and how you approach your recovery. Know that help is available and remission and full recovery is possible. If you or a loved one are experiencing symptoms of bulimia, reach out to eating disorder organizations like the National Eating Disorder Information Center for help.

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