Introduction

Bulimia nervosa is an eating disorder and mental health condition.

People who have bulimia try to control their weight by severely restricting the amount of food they eat, then binge eating and purging the food from their body by making themselves vomit or using laxatives

As with other eating disorders, bulimia nervosa can be associated with:

Learn more about the causes of bulimia nervosa.

Binge eating and purging

Eating disorders are often associated with an abnormal attitude towards food or body image.

Everyone has their own eating habits – for example, people with a food intolerance need to avoid eating certain foods to stay healthy. However, people suffering from eating disorders tend to use their eating habits and behaviours to cope with emotional distress, and often have an abnormal or unrealistic fear of food, calories and being fat.

Because of this fear, people with bulimia nervosa tend to restrict their food intake. This results in periods of excessive eating and loss of control (binge eating), after which they make themselves vomit or use laxatives (purging). They purge themselves because they fear that the binging will cause them to gain weight, and usually feel guilty and ashamed of their behaviour. This is why these behaviours are usually done in secret.

Such binge-purge cycles can be triggered by hunger or stress, or are a way to cope with emotional anxiety.

Warning signs

Signs of bulimia nervosa include an obsessive attitude towards food and eating, an overcritical attitude to their weight and shape, and frequent visits to the bathroom after eating, after which the person might appear flushed and have scarred knuckles (from forcing fingers down the throat to bring on vomiting).

Read more about the symptoms and warning signs of bulimia.

Bulimia can eventually lead to physical problems associated with poor nutrient intake, excessive vomiting or overuse of laxatives. Read more about these complications of bulimia.

Who is affected by bulimia nervosa?

As with all eating disorders, women are much more likely to develop bulimia than men.

However, bulimia nervosa is becoming increasingly common in boys and men. There are an estimated 1.6 million Britons suffering from some form of eating disorder, and reports estimate that up to 25% may be male.

Recent studies suggest that as many as 8% of women have bulimia at some stage in their life. The condition can occur at any age, but mainly affects women aged between 16 and 40 (on average, it starts around the age of 18 or 19).

Bulimia nervosa can affect children, but this is extremely rare. 

What to do

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem. Then, you need to visit your GP for a medical check-up and advice on how to get treatment.

If you think someone you know has bulimia nervosa, talk to them and try to persuade them to see their GP.

There are also many support groups and charities you can approach for help, including:

Read about diagnosing bulimia.

The first step towards getting better is to recognise the problem and to have a genuine desire to get well.

There is strong evidence that self-help books can be effective for many people with bulimia nervosa, especially if they ask a friend or family member to work through it with them.

If this is not suitable or is unsuccessful, your GP can refer you for treatment to an eating disorder service, where you may be offered a structured programme of cognitive behavioural therapy (CBT). Some people may also benefit from antidepressant medication (fluoxetine), as this can reduce the urges to binge and vomit.

Read more about the treatment of bulimia.

Symptoms

The main signs of bulimia are binge eating and purging (ridding your body of food by making yourself vomit or taking laxatives).

There may also be psychological symptoms, such as:

  • an obsessive attitude towards food and eating
  • unrealistic opinions about body weight and shape
  • depression and anxiety
  • isolation – losing interest in other people

Without treatment, bulimia can lead to a number of physical complications. Read more about complications of bulimia.

Binge eating

Binge eating is repeatedly eating vast quantities of high-calorie food, without necessarily feeling hungry or needing to eat. The urge to eat can begin as an attempt to deal with emotional problems, but can quickly become obsessive and out of control.

Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.

Binge eating episodes are sometimes spontaneous, where you eat anything you can find. They can also be planned, where you make a shopping trip to buy foods specifically to binge on.

Read more information about binge eating.

Purging

Purging is a response to binging. After you have eaten lots of food in a short space of time, you may feel physically bloated and unattractive. You may also feel guilty, regretful and full of self-hatred.

However, the main impulse to purge is a powerful, overriding fear of putting on weight.

The most common methods of purging involve making yourself vomit or using laxatives to encourage your body to pass the food quickly.

Less common methods of purging include taking diet pills, over-exercising, extreme dieting, periods of starvation or taking illegal drugs, such as amphetamines.

Cycle of guilt

Bulimia is often a vicious circle. If you have the condition, it is likely that you have very low self-esteem. You may also think you are overweight, even though you may be at or near a normal weight for your height and build.

This may encourage you to set yourself strict rules about dieting, eating or exercising, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have denied yourself. After feeling guilty about binging, you purge to get rid of the calories.

Causes

There is no simple answer to the question of what causes bulimia. Although the condition is linked to a fear of getting fat, more complex emotions usually contribute.

The act of binging and purging is often a way of dealing with these intense emotions.

Common emotional causes

Common problems that may lead to bulimia include:

  • low self-esteem – if you have an eating disorder, you may have a low opinion of yourself and see losing weight as a way of gaining self-worth
  • depression – you may use binging as a way of coping with unhappiness, but purging does not relieve this depression and the cycle continues
  • stress – for example, you may develop the condition after dealing with a traumatic experience, such as a death or divorce, or during the course of important life-changing events, such as getting married or leaving home

Bulimia can also occur in people who have experienced physical illness, and in people who have been sexually abused. Some people with bulimia have experienced a difficult childhood, with family problems, arguments and criticism.

Other mental health problems

Bulimia is often linked to other psychological problems. Research shows that bulimia is more common in people who have:

Cultural and social pressure

Some people believe that the media and fashion industries create pressure for people to aspire to low body weights.

Puberty

Many young people become affected by eating disorders around the time of puberty, when hormonal changes can make them more aware of their body.

If teenagers feel they have no say in their lives, bulimia can seem like the only way to take control.

Genetics

There may be a genetic factor related to developing bulimia. Research suggests that people who have a close relative who has or has had bulimia are four times more likely to develop it than those who do not have a relative with the condition.

Men and bulimia

The causes of bulimia in men can be slightly different. In many cases, bulimia develops because of bodybuilding or specific occupations like athletics, dancing or horse racing.

However, like many women, younger men are increasingly becoming more vulnerable to disliking their bodies and being bullied or teased as children for being overweight.

Diagnosis

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your GP. You may think it is not serious, but bulimia can damage your long-term health.

Accepting that you need help and support is the first step to recovery, but this may be a very difficult step for you to take. Most people who have bulimia hide their situation for months or years before seeking help. It can often take a change of situation, such as the start of a new relationship or living with new people, to make a person with bulimia want to seek help.

It may help to make a list of questions you want to ask before you see your GP. Once you have explained your situation to your GP, they will decide whether to refer you to a specialist mental health team.

Your local team will include:

  • specialist counsellors
  • psychiatrists
  • psychologists
  • nurses
  • dietitians
  • other healthcare professionals

Your treatment depends on how serious your condition is and the best way to manage it. Your GP may recommend a self-help programme to start your recovery before referring you for specialist treatment.

You can make a full recovery from bulimia. The earlier you start treatment, the quicker the recovery process will be.

Do I have an eating disorder?

Doctors sometimes use a questionnaire called the SCOFF questionnaire to help recognise people who may have an eating disorder. This involves answering the following five questions:

  • Scoff: Do you ever make yourself vomit because you feel uncomfortably full?
  • Control: Do you worry you have lost control over how much you eat?
  • One stone: Have you recently lost more than one stone (six kilograms) in a three-month period?
  • Fat: Do you believe yourself to be fat when others say you are too thin?
  • Food: Would you say that food dominates your life?

If you answer “yes” to two or more of these questions, you may have an eating disorder.

Treatment

You can recover from bulimia, but it may be a long and difficult process. The first step towards getting better is to recognise the problem and have a genuine desire to get well. This may involve a big change in lifestyle and circumstances.

If you are concerned about a friend or family member, it can be difficult to know what to do. It is common for someone with an eating disorder to be secretive and defensive about their eating and their weight, and they will probably deny being unwell.

You can talk in confidence to an adviser from eating disorders charity Beat by calling their helpline on 0845 634 1414. They also have a designated youth helpline, on 0845 634 7650.

Treatment usually begins with psychological therapy, which aims to help re-establish healthy attitudes towards eating. People with bulimia need to explore and understand the underlying issues and feelings that are contributing to their eating disorder, and change their attitudes to food and weight. 

Your GP may suggest medication, usually in addition to psychological treatment.

Psychological treatment

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is the most common type of psychological treatment for bulimia. It involves talking to a therapist and looking at your emotions in detail to work out new ways of thinking about situations, feelings and food. It may also involve keeping a food diary, which will help determine what triggers your binge eating.

Interpersonal therapy

As with CBT, interpersonal therapy (IPT) involves meeting with a therapist to discuss your condition. However, the focus is more on your personal relationships than your problems with food.

You are more likely to be referred for this type of psychological treatment if you have recently lost a loved one or have experienced a big change in your life. The aim of IPT is to help you establish supportive relationships, which can draw your focus away from eating.

Medication

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may be used to treat bulimia. The SSRI usually recommended to treat bulimia is called fluoxetine (brand name Prozac).

SSRIs are mainly used to treat depression, but are also used to treat:

As with any antidepressant, an SSRI will usually take several weeks before it starts to work. You will usually be started on a low dose, which is then gradually increased as your body adjusts to the medicine.

When you start taking an SSRI, see your GP after two, four, six and twelve weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it's important that your progress is carefully monitored.

Very few drugs are recommended for children and young people below the age of 18. It is also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.

Hospital treatment

Bulimia is not usually treated in hospital. However, if you have serious health complications and your life is at risk, you may be admitted to hospital. Hospital treatment is also considered if you are at risk of suicide or self-harm.

The recovery process

Once diagnosed, people with bulimia can recover, but it may take a long time. It can be very difficult, both for the person affected and their family and friends.

To recover, someone with bulimia needs to:

  • change their eating habits
  • change the way they think about food
  • gain weight safely, if necessary

The longer someone has had bulimia, the harder it is to re-learn healthy eating habits and gain weight. It is important to start treatment as early as possible, so the person has the best chance of recovery.

For most people, recovery goes through several stages, with progress seeming to go backwards and forwards.

Complications

There are a number of physical complications associated with bulimia.

These can include any of the following:

  • Dental problems – persistent vomiting can cause your stomach acid to damage the enamel on your teeth, which may lead to tooth decay. Excessive vomiting can also cause bad breath and a sore throat.
  • Irregular periods – your menstrual cycle can become unpredictable, or even stop altogether. You may also find it difficult to become pregnant in the future.
  • Poor skin and hair – a lack of nutrients through persistent vomiting or laxative use can make your skin and hair unhealthy. Your skin and hair can become dry and your fingernails can become brittle.
  • Swollen glands – if you have bulimia, your saliva glands can become swollen from frequent vomiting. This makes your face appear rounder.
  • Chemical imbalance – excessive vomiting and laxative use can cause chemical imbalances in your body. This can result in tiredness, weakness, abnormal heart rhythms, kidney damage, convulsions (fits) and muscle spasms.
  • Bowel problems – excessive use of laxatives can damage your bowel muscles, resulting in permanent constipation.
  • Heart problems – long-term complications of bulimia can include an increased risk of heart problems.