Bulimia nervosa is a serious eating disorder. People with bulimia nervosa are overly concerned with their body’s shape and weight and engage in detrimental behaviors in an attempt to control their body image. Bulimia nervosa is often characterized by a destructive pattern of binging (eating too much unhealthy food) and inappropriate, reactionary behaviors to control one’s weight following these episodes.
Binge eating is the rapid consumption of an unusually-large amount of food in a short period of time. Unlike simple overeating, people who binge feel “out of control” during these episodes. This means that one “cannot stop the urge to eat” once it has begun, even after their stomach is full. Binging may “feel good” initially, but it quickly becomes distressing for the person who is absorbed in this behavior. Food is often eaten secretly and quickly. A binge is usually ended only with abdominal discomfort, social interruption or running out of food. When the binge is over, the person with bulimia often feels guilty and will engage in inappropriate behaviors to rid their body of the excess calories that were eaten.
Inappropriate behaviors to control one’s weight can include purging. Purging behaviors are potentially dangerous and can consist of a wide variety of actions “to get rid of everything I ate.” This can include self-induced vomiting, the abuse of laxatives, enemas or diuretics (e.g., caffeine). Other behaviors such as “fasting” or restrictive dieting following binge-eating episodes are also common, as well as excessive exercising.
Bulimia nervosa is often under-diagnosed because many people who experience this illness may be of normal weight (or even overweight), as opposed to individuals with anorexia nervosa. The typical age of onset for bulimia nervosa is late adolescence or early adulthood, but onset can and does occur at any time throughout the lifespan. Like other eating disorders, bulimia nervosa mainly affects females, although at least one in 10 individuals with this condition is male. Bulimia nervosa is more common than anorexia nervosa and likely occurs in up to three percent of the population. Like all mental illnesses, Bulimia nervosa is found in all racial, religious, ethnic and socioeconomic groups.
Bulimia nervosa often occurs with other psychiatric disorders such as mood disorders (e.g., depression), anxiety disorders (e.g., obsessive-compulsive disorder), substance abuse disorders, and disorders of self-injurious behavior (e.g., borderline personality disorder). Many people with bulimia nervosa will also be diagnosed with anorexia nervosa or another eating disorder at some point in their lives. As with any other condition, adequate treatment of coexisting mental illnesses is necessary goal of treatment in bulimia nervosa.
Constant obsession with food and weight is a primary sign of bulimia nervosa. Other important indicators are signs of binging (e.g., hidden candy wrappers under a bed or multiple empty cereal boxes stuffed in a closet) and purging (e.g., boxes of laxatives or enemas stored in one’s desk without a clear medical indication for these products).
People with bulimia may also experience irregular menstrual periods or depressed mood. These symptoms may cause a person to go to their doctor. Similarly, doctors may also find they are examining their patients for unexplained stomach pain or sore throat before a diagnosis of bulimia nervosa is made.
Doctors may see common signs of self-induced vomiting including unexplained damage to the teeth (due to the acidity of vomit) and scarring on the backs of the hands and fingers (due to repeatedly pushing fingers down the throat to induce vomiting). A number of people with bulimia will have swollen cheeks (due to damage of their parotid glands).
People with bulimia nervosa—even if their weight remains “normal”—can severely damage their bodies by binging and purging. Self-induced vomiting can injure the various parting of the body involved in eating and digesting food: tooth decay, esophageal and stomach injury, and acid reflux are all common in people with bulimia nervosa. Excessive purging behaviors can cause dehydration and changes in the body’s electrolytes (e.g., low potassium). This can lead to multiple problems including cardiac arrhythmias, heart failure and even death.
Although the precise causes of bulimia nervosa are unknown, scientists agree that it is caused by a combination of genetic and environmental factors. People with a family history of eating disorders or a personal history of mental illness, including depression, anxiety, substance abuse and other illnesses, are more likely to develop bulimia nervosa. Traumatic events (e.g., physical or sexual abuse) as well as life-stressors (including being bullied at school) can also increase the risk of developing bulimia nervosa. While no specific region of the brain has been directly connected with bulimia nervosa, certain chemicals in the brain (e.g., the neurotransmitter serotonin) have been shown to have a relationship with binging and purging behaviors.
The most important thing to do in the treatment of bulimia nervosa is to ensure good medical treatment. As mentioned above, bulimia can cause serious medical complications and before anything else can be done, a thorough medical evaluation—either by a primary care provider or in the hospital setting—should be performed in order to ensure the individual’s safety.
Similar to other eating disorders, therapy is a cornerstone of treatment in bulimia nervosa. Individual therapy can include a wide-variety of techniques: cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) have been shown in scientific studies to decrease the symptoms of bulimia nervosa. Group psychotherapy can be useful in helping individuals with a supportive, therapeutic environment to discuss the challenges they face throughout treatment. Family psychotherapy can be useful in helping to support both the individual with bulimia nervosa and their family members. Nutritional counseling is useful in guiding individuals towards a healthy diet and regular eating habits.
Many medications have been used to treat symptoms of bulimia nervosa, the specifics of which are beyond the scope of this review. The only FDA approved medication for bulimia nervosa is fluoxetine (Prozac). This medication helps by decreasing the symptoms of bulimia nervosa, but it does not cure the illness. As with any other mental illness, it is important to discuss any medication decisions with one’s psychiatrist and other members of the treatment team.
With thorough treatment and the support of their loved ones, most people with bulimia nervosa can expect to see a significant decrease in their symptoms and to live healthy lives in absence of serious medical complications. Family members and friends can be most helpful in providing nonjudgmental support of their loved one and by encouraging their loved one to seek treatment for this serious mental illness.
Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., January 2013