Bulimia (boo-LEE-me-uh) nervosa, commonly called bulimia, is a serious, potentially life-threatening eating disorder. People with bulimia may secretly binge — eating large amounts of food — and then purge, trying to get rid of the extra calories in an unhealthy way. For example, someone with bulimia may force vomiting or do excessive exercise. Sometimes people purge after eating only a small snack or a normal-size meal.
Bulimia can be categorized in two ways:
- Purging bulimia. You regularly self-induce vomiting or misuse laxatives, diuretics or enemas after bingeing.
- Nonpurging bulimia. You use other methods to rid yourself of calories and prevent weight gain, such as fasting, strict dieting or excessive exercise.
However, these behaviors often overlap, and the attempt to rid yourself of extra calories is usually referred to as purging, no matter what the method.
If you have bulimia, you're probably preoccupied with your weight and body shape, and may judge yourself severely and harshly for your self-perceived flaws. Because it's related to self-image — and not just about food — bulimia can be difficult to overcome. But effective treatment can help you feel better about yourself, adopt healthier eating patterns and reverse serious complications.
Bulimia signs and symptoms may include:
- Being preoccupied with your body shape and weight
- Living in fear of gaining weight
- Feeling that you can't control your eating behavior
- Eating until the point of discomfort or pain
- Eating much more food in a binge episode than in a normal meal or snack
- Forcing yourself to vomit or exercise too much
- Misusing laxatives, diuretics or enemas after eating
- Using dietary supplements or herbal products for weight loss
When to see a doctor
If you have any bulimia symptoms, seek medical help as soon as possible. If left untreated, it may get worse and take over your life.
Talk to your primary care provider or a mental health provider about your bulimia symptoms and feelings. If you're reluctant to seek treatment, confide in someone about what you're going through, whether it's a friend or loved one, a teacher, a faith leader or someone else you trust. He or she can help you take the first steps to successful bulimia treatment.
Helping a loved one with bulimia symptoms
If you think a loved one may have symptoms of bulimia, have an open and honest discussion about your concerns. You can't force someone to seek professional care, but you can offer encouragement and support. You can also help find a qualified doctor or mental health provider, make an appointment and even offer to go along.
Because most people with bulimia are of normal weight or even slightly overweight, it may not be apparent to others that something is wrong. Red flags that family and friends may notice include:
- Constantly worrying or complaining about being fat
- Having a distorted, excessively negative body image
- Repeatedly eating unusually large quantities of food in one sitting, especially high-fat or sweet foods
- Not wanting to eat in public or in front of others
- Going to the bathroom right after eating or during meals
- Exercising too much
- Having sores, scars or calluses on the knuckles or hands
- Having damaged teeth and gums
The exact cause of bulimia is unknown. There are many possible factors that could play a role in the development of eating disorders. But biology, emotional health, societal expectations and other factors increase your risk
Factors that increase your risk of bulimia may include:
- Being female. Girls and women are more likely to have bulimia than boys and men are.
- Age. Bulimia often begins in the late teens or early adulthood.
- Biology. People with first-degree relatives (siblings or parents) with an eating disorder may be more likely to develop an eating disorder, suggesting a possible genetic link. It's also possible that a deficiency in the brain chemical serotonin may play a role.
- Psychological and emotional issues. People with eating disorders may have psychological and emotional problems that contribute to the disorder. Examples include low self-esteem, perfectionism, impulsive behavior, anger management problems, depression, anxiety disorders or obsessive-compulsive disorder. In some cases, traumatic events may be a contributing factor.
- Societal pressure. Peer pressure and what people see in the media may fuel a desire to be thin, particularly among young women. People who are in the public eye, such as actors, dancers and models, are at higher risk of eating disorders.
- Performance pressure in sports. Eating disorders are particularly common among athletes, such as gymnasts, runners and wrestlers. Coaches and parents may unknowingly contribute to eating disorders by encouraging young athletes to lose weight, maintain a low weight and restrict eating for better performance.
Bulimia may cause numerous serious and even life-threatening complications. Possible complications include:
- Dehydration, which can lead to major medical problems, such as kidney failure
- Heart problems, such as an irregular heartbeat and heart failure
- Severe tooth decay and gum disease
- Absence of a period in females
- Digestive problems, and possibly a dependence on laxatives to have bowel movements
- Anxiety and depression
- Drug and alcohol abuse
Here's some information to help you get ready for your appointments, and what to expect from your health care team.
What you can do
- Write down your symptoms, even those that may seem unrelated to bulimia.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications you're taking, as well as any herbs, vitamins or supplements.
- Ask a family member or friend to come with you, if possible, to help you remember key points and give a fuller picture of the situation and your home life.
Write down questions to ask your doctor, such as:
- What kinds of tests do I need? Do these tests require any special preparation?
- What treatments are available, and which do you recommend?
- Is there a generic alternative to the medicine you're prescribing me?
- How will treatment affect my weight?
- Will my periods begin again?
- Are there any brochures or other printed material I can take home with me? What websites do you recommend?
Don't hesitate to ask questions at any time if you don't understand something.
What to expect from your doctor
Your doctor or other health care provider will likely ask you several questions to determine if you have bulimia, such as:
- How long have you been worried about your weight?
- Do you exercise? How often do you exercise?
- Have you found any other ways to lose weight?
- Are you having any physical symptoms?
- Have you ever vomited because you were uncomfortably full?
- Have you ever taken medications for weight loss?
- Do you think about food often?
- Do you ever eat in secret?
- Have any of your family members ever had symptoms of an eating disorder, or have any been diagnosed with an eating disorder?
Your doctor will ask additional questions based on your responses, symptoms and needs.
When doctors suspect you have bulimia, they typically perform:
- A complete physical exam
- Blood and urine tests
- A psychological evaluation, including a discussion of your eating habits and attitude toward food
Your doctor may also request an X-ray to check for broken bones, pneumonia or heart problems and an electrocardiogram (EKG) to look for heart irregularities.
These tests help doctors determine if you have bulimia or another eating disorder, such as anorexia or binge-eating disorder.
Diagnostic criteria for bulimia
To be diagnosed with bulimia, you must meet these criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association:
- You repeatedly binge, eating an abnormally large amount of food, and feel that you can't control your eating.
- You get rid of the extra calories from bingeing by vomiting, excessive exercise, fasting, or misuse of laxatives, diuretics, enemas or other medications.
- You binge and purge at least twice a week for at least three months.
- Your body shape and weight influence your feelings of self-worth too much.
- You don't have anorexia, an eating disorder with extremely restrictive eating behaviors.
Even if you don't meet all of these criteria, you could still have an eating disorder. Don't try to diagnose yourself — get professional help if you have any eating disorder symptoms.
When you have bulimia, you may need several types of treatment, although combining psychotherapy with antidepressants may be the most effective for overcoming the disorder. Treatment generally involves a team approach that includes you, your family, your primary care doctor or other medical provider, as well as a mental health provider and a dietitian experienced in treating eating disorders. You may have a case manager to coordinate your care.
Here's a look at bulimia treatment options and considerations:
Psychotherapy involves talking about your bulimia and related issues with a mental health provider. Psychotherapy is also known as talk therapy, counseling or psychosocial therapy. There's evidence that these types of psychotherapy help improve symptoms of bulimia:
- Cognitive behavioral therapy to help you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones
- Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills
- Dialectical behavior therapy to help you learn behavioral skills to tolerate stress, regulate your emotions and improve your relationships with others — all of which can reduce the desire to binge eat
- Family-based treatment to help parents intervene to stop their teenager's unhealthy eating behaviors, then to help the teen regain control over his or her own eating, and lastly to help the family deal with problems the bulimia can have on the teen's development and the family
Ask your mental health provider which psychotherapy he or she will use and what evidence exists that shows it's beneficial in treating bulimia.
Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI), which may help even if you're not depressed.
Nutrition education and achieving healthy weight
If you're underweight due to bulimia, the first goal of treatment will be to start getting you back to a healthy weight. Dietitians and other health care providers can design an eating plan to help you achieve a healthy weight, normal eating habits and good nutrition. If you have binge-eating disorder, you may benefit from medically supervised weight-loss programs.
Bulimia can usually be treated outside of the hospital. But if you have a severe form and serious health complications, you may need treatment in a hospital. Some eating disorder programs may offer day treatment, rather than inpatient hospitalization.
Treatment challenges in bulimia
Although most people with bulimia do recover, some find that symptoms don't go away entirely. Periods of bingeing and purging may come and go through the years, depending on your life circumstances, such as times of high stress. If you find yourself back in the binge-purge cycle, "booster" sessions with your health care providers may help you weather the crisis before your eating disorder spirals out of control again. Learning positive ways to cope, creating healthy relationships and managing stress can help prevent a relapse.
Although you can't treat bulimia on your own, you can build on your treatment plan. In addition to professional treatment, follow these self-care tips for bulimia:
- Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
- Get the right nutrition. Talk to your doctor about appropriate vitamin and mineral supplements. If you aren't eating well or you're frequently purging, it's likely your body isn't getting all of the nutrients it needs.
- Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
- Stay in touch. Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart and that nurturing, caring relationships are healthy for you.
- Be kind to yourself. Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
- Be cautious with exercise. Talk to your health care providers about what kind of physical activity, if any, is appropriate for you, especially if you exercise excessively to burn off post-binge calories.
Although complementary and alternative therapies to reduce bulimia symptoms have not been studied, some therapies, such as those below, may help achieve the goals set by you and your health care team.
- Massage and therapeutic touch may help to reduce anxiety often associated with eating disorders.
- Mind-body therapies, such as meditation, yoga, biofeedback and hypnosis, may increase awareness of your body's cues for eating and fullness, as well as promote a sense of well-being and relaxation.
- Acupuncture shows promise in studies on anxiety and depression, but hasn't been proved effective at this point.
Risks of herbs and dietary supplements
Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with eating disorders. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications. If you use dietary supplements or herbs, discuss the potential risks with your doctor.
You may find it difficult to cope with bulimia when you're hit with mixed messages by the media, culture, coaches, family, and maybe your own friends or peers. So how do you cope with a disease that can be deadly when you're also getting messages that being thin is a sign of success?
- Remind yourself what a healthy weight is for your body.
- Resist the urge to diet or skip meals, which can trigger binge eating.
- Don't visit websites that advocate or glorify eating disorders.
- Identify troublesome situations that are likely to trigger thoughts or behaviors that may contribute to your bulimia and develop a plan to deal with them.
- Have a plan in place to cope with the emotional distress of setbacks.
- Look for positive role models who can help boost your self-esteem.
- Find pleasurable activities and hobbies that can help to distract you from thoughts about bingeing and purging.
- Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement.
If you have bulimia, you and your family may find support groups helpful for encouragement, hope and advice on coping. Group members can truly understand what you're going through because they've been there. Ask your doctor if he or she knows of a group in your area.
Coping advice for parents
If you're the parent of someone with bulimia, you may blame yourself for your child's eating disorder. But, eating disorders have many causes, and it's better not to waste time trying to figure out why the eating disorder occurred. Instead, focus on how you can help your child now.
Here are some suggestions for supporting your child:
- Ask your child what you can do to help. For example, offer to keep certain trigger foods out of the house. Ask if your teenager would like you to plan family activities after meals to reduce the temptation to purge.
- Listen. Allow your child to express feelings.
- Schedule regular family mealtimes. Eating at routine times is important to help reduce binge eating.
- Let your teenager know any concerns you have. But do this without placing blame.
Remember that eating disorders affect the whole family, and you need to take care of yourself, too. If you feel that you aren't coping well with your teen's illness, you might benefit from professional counseling. Or ask your child's doctor about support groups for parents of children with eating disorders.
Although there's no sure way to prevent bulimia, you can steer someone toward healthier behavior or professional treatment before the situation worsens. Here's how you can help:
- Cultivate and reinforce a healthy body image in your children no matter what their size or shape.
- Talk with your pediatrician. Pediatricians may be in a good position to identify early indicators of an eating disorder and help prevent its development.
- If you notice a relative or friend who seems to have food issues that could lead to or indicate an eating disorder, consider supportively talking to the person about these issues and ask how you can help.
Apr. 03, 2012
- Eating disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Arlington, Va.: American Psychiatric Association; 2000. http://www.psychiatryonline.com. Accessed Jan. 17, 2012.
- Longo DL, et al. Harrison's Online. 18th ed. New York, N.Y.: The McGraw-Hill Companies; 2012. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=4.. Accessed Jan. 17, 2012.
- Forman SF. Eating disorders: Epidemiology, pathogenesis and clinical features. http://www.uptodate.com/index. Accessed Jan 26, 2012.
- Ebert MH, et al. Current Diagnosis & Treatment: Psychiatry. 2nd ed. New York, N.Y.: The McGraw-Hill Companies; 2008. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=10. Accessed Jan. 17, 2012.
- Forman SF. Eating disorders: Treatment and outcome. http://www.uptodate.com/index. Accessed Jan. 26, 2012.
- Breuner CC. Complementary, holistic, and integrative medicine: Eating disorders. Pediatrics in Review. 2010;31:c75.
- Carei TR, et al. Randomized controlled clinical trial of yoga in the treatment of eating disorders. Journal of Adolescent Health. 2010;46:346.
- Binge eating disorder. National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov/publications/binge.htm. Accessed Jan. 31, 2012.
- LeGrange D, et al. Calculation of expected body weight in adolescents with eating disorders. Pediatrics. 2012;129:1.
- Sim LA, et al. Identification and treatment of eating disorders in the primary care setting. Mayo Clinic Proceedings. 2010;85:746.
- Interpersonal psychotherapy for depressed adolescents (IPT-A). National Registry of Evidence-based Programs and Practices (NREPP) Substance Abuse and Mental Health Services (SAMHS). http://nrepp.samhsa.gov/ViewIntervention.aspx?id=198. Accessed Jan. 26, 2012.
- Loeb KL, et al. Transdiagnostic theory and application of family-based treatment for youth with eating disorders. Cognitive and Behavioral Practice. 2012;1:17
- Hall-Flavin DK (expert opinion). Mayo Clinic Rochester, Minn. Feb. 22, 2012.
- Sim LA (expert opinion). Mayo Clinic Rochester, Minn. Mar. 14, 2012.