Bulimia Nervosa is a serious and sometimes fatal mental health condition that involves disordered eating patterns. People with bulimia alternate between eating large quantities of food (binge eating) and engaging in activities or behaviors to avoid weight gain (compensatory behaviors, like purging). These behaviors are influenced in part by a poor body image or a preoccupation with weight.
Bulimia is often treated with outpatient counseling, nutritional intervention, medication, and/or intensive outpatient or inpatient care. Bulimia is a chronic condition, and one that will require ongoing monitoring. Even after a prolonged period of recovery, it is important to watch for signs of relapse, especially during times of high stress.
Types of Bulimia
Bulimia falls within the category of eating disorders, which are a cluster of disorders characterized by unhealthy eating habits, which can be driven by a preoccupation with weight or body image. There are two subtypes of bulimia which differentiate between types of unhealthy behaviors people engage in after binge eating episodes: purging and non-purging.
People with the purging type of bulimia tend to fit within the more stereotyped view of the disorder because they alternate between binging and purging behaviors. Purging can refer to self-induced vomiting, but it can also refer to the misuse of laxatives, diuretics, or enemas to evacuate the bladder or bowels.
People with the non-purging type of bulimia engage in other “compensatory behaviors” to avoid weight gain after a binge. Compensatory behaviors include restricting food intake and compulsive exercising. People with this subtype do not regularly engage in purging behaviors.
Signs of Bulimia Nervosa
Bulimia is an eating disorder that, like other mental health disorders, causes observable changes in a person’s body, brain, and behavior. Bulimia can be difficult to detect because unlike anorexia, people with the disorder may be at or around a normal weight or could be overweight. Bulimia can also be difficult to detect because people with the disorder may eat normal portions of food when they are around others, only binge eating or purging in secrecy.
Doctors and other medical providers are sometimes the first to identify signs of an eating disorder during other routine appointments with their patients. Eating disorders like bulimia place a large amount of stress on the body and can cause several health complications.
Bulimia-induced health problems include:1
- Electrolyte imbalance
- Tooth decay or missing enamel
- Acid reflux
- Cough or sore throat
- Esophageal ulcers, erosion, or ruptures
- Heart arrhythmias
- Increased instances of miscarriage
- Gastrointestinal injury and complication from long term laxative abuse
Other physical changes or health issues related to bulimia that may be observed by medical professionals or those who are close to people include:
- Fluctuations in weight
- Dry skin
- Brittle nails
- Cuts or calluses on tops of fingers
- Dental issues like stained teeth or cavities
- Increased sensitivity to cold temperatures
- Growth of additional body hair
- Thinning hair or hair loss
- Fatigue or weakness
- Trouble sleeping
- Complaints of GI pain or issues
- Missed or irregular menstrual periods
Changes in mood and mental health are also commonly observed in people with bulimia. These can include:
- Increased moodiness or irritability
- Lowered self esteem and poor body image
- Withdrawal from friends and normal activities and routines
- Self-harming behaviors (ie: cutting)
- Frequent self-criticism, self-loathing, or shame
- Preoccupation with weight, food, or appearance
Behavior changes are usually the most obvious signs of bulimia. Some common behavior patterns noted in people with bulimia include:
- Frequent trips to the bathroom after eating
- Secrecy around food or eating or refusal to eat around others
- Hoarding of food
- Fascination or interest in weight loss fads
- Always reporting being on a diet
- Intake of weight loss supplements, laxatives, or diuretics
- Frequent body checking behaviors (pinching fat, checking the mirror, etc)
- Drinking excessive liquids
- Constant use of breath mints, gum, or mouthwash
- Frequent self-critical comments, especially those about weight or appearance
- Consumption of large amounts of food or eating to the point of discomfort
- Stress eating
Symptoms of Bulimia Nervosa
Mental health conditions are diagnosed by licensed health or mental health professionals. A standard set of criteria is used to determine whether a person has a disorder, and the symptoms and criteria is outlined in the Diagnostic and Statistical Manual of Mental Disorders (or the DSM 5).
According to the DSM 5, the symptoms of bulimia are:2
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within a two hour period), an amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances.
- Lack of control over eating during the episode (e.g., a feeling that you cannot stop eating, or control what or how much you are eating).
- Recurrent inappropriate compensatory behavior 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 both occur, on average, at least once a week for three months.
- Self-evaluation is unduly influenced by body shape and weight.
- Binging or purging does not occur exclusively during episodes of behavior that would be common in those with anorexia nervosa.
During the assessment process, the clinician will also specify which subtype of bulimia a person has, either the purging or non-purging type.
The severity of bulimia varies, ranging from mild to extreme. Severity is determined by a clinician and depends on the average number of times a person reports purging or engaging in other compensatory behaviors.
Severity of bulimia is diagnosed using the following guidelines:
- Mild bulimia: an average of 1-3 purging/compensatory behaviors per week
- Moderate bulimia: an average of 4-7 purging/compensatory behaviors per week
- Severe bulimia: An average of 8-13 purging/compensatory behaviors per week
- Extreme bulimia: An average of 14 or more purging/compensatory behaviors per week
Causes and Triggers of Bulimia Nervosa
All mental health conditions are caused by a complex interaction of biological, psychological and environmental factors. No singular factor causes bulimia, but some factors do increase a person’s risk of developing the disorder.
Some of the social and environmental risk factors for bulimia include:3
- Being the victim of childhood sexual abuse
- Living in a sorority house
- Being involved in athletic activities
- Being in an occupation that focuses on weight or appearance
- A tendency to eat alone
- Parents who had high expectations or who were highly critical
- Parents who abused alcohol
- Parents who were often unavailable
Certain populations are also more likely to develop bulimia than others. Populations at higher risk include:3
- Teens and young adults
- Gay males
- Caucasian women
- People living in industrialized countries
Biological, psychological, and personality risk factors include:4
- A family history of an eating disorder
- Childhood obesity
- Early puberty
- Perfectionistic personalities
- Low self-esteem
- Poor mood regulation
- Poor impulse control
- Concern about weight or appearance in teenage years
- Fear of weight gain
- Existing mental health disorder like depression or anxiety
- Personality disorders
- Substance abuse, particularly tobacco, alcohol, and stimulant abuse
Treatment of Bulimia Nervosa
There are several effective treatment options for people struggling with bulimia. It is recommended that people make treatment decisions in collaboration with a licensed health or mental health professional. This increases the likelihood of being matched with treatment that makes the most sense for you, your budget, and the severity of your symptoms.
Options for treating bulimia include:
Typically, outpatient counseling occurs with a licensed therapist, counselor, or psychologist in office settings. Sessions may vary in frequency and length, but the average is once- or twice-weekly sessions that last about an hour. Sessions might be conducted individually or with family members or other support people, depending on the individual needs and preferences of the client. Group therapy is also sometimes an option. Therapists differ in their training and treatment approach, and many approaches could be effective. The therapies that currently have the most research for effectively treating eating disorders are Cognitive Behavioral Therapy (CBT)4 and Family-based treatments.5
In many cases, nutritional intervention is recommended in addition to other forms of treatment for eating disorders. Nutritional guidance should be provided by a Registered Dietician (RD) who is well-versed in the treatment of eating disorders. The particular recommendations the dietician makes will vary depending on an assessment of the client’s current weight, health, and nutritional needs. The involvement of a dietician helps to ensure that a person in recovery from bulimia is getting their caloric and nutritional needs met in a safe and healthy way.
In some instances, a doctor, psychiatrist or other prescribing medical professional will be involved in treatment for an eating disorder. The purpose of medication may be to address underlying health issues related to or caused by the eating disorder and in other instances, medication may be prescribed to treat other co-occurring mental health conditions. Even for people without existing mental health conditions, antidepressants, particularly SSRI’s, have been effective in the treatment of bulimia.4
Intensive Outpatient and Partial Hospitalization
Intensive outpatient and partial hospitalization programs that specialize in eating disorders are sometimes recommended for individuals who have more severe symptoms or who are stepping down from inpatient or residential care. These structured programs are offered several days a week for partial or full day treatments and can involve a mix of individual and group therapy, nutritional and medical consults, and other treatment-related activities. Often, these programs employ an interdisciplinary team that includes Registered Dieticians, counselors, and doctors. This interdisciplinary team provides more comprehensive wrap-around services to those recovering from eating disorders.
Residential or Inpatient Treatment
In some instances, more intensive treatment is needed. Residential treatments are places where several people recovering from eating disorders can stay for weeks or months at a time while they receive comprehensive treatment. Other inpatient facilities provide more intensive medical monitoring and more comprehensive medical or psychological treatment to higher risk patients. These facilities are typically similar to hospitals (and sometimes located within a hospital) and involve several doctors and medical professionals who help provide specialized treatment.
Bulimia vs Other Eating Disorders
While bulimia can be confused with other eating disorders, it is important to note a few key differences, the biggest being the continuous cycle of binging and compensatory behaviors (like purging).
Bulimia Nervosa vs Anorexia Nervosa
The two eating disorders most commonly confused are anorexia nervosa and bulimia nervosa. Alternating between episodes of binge eating and restricting/purging can be a component of both disorders. The primary differentiating factor is that anorexia is diagnosed when the disordered eating behaviors have resulted in significantly low body weight. Someone who displays these behaviors but who is not underweight is more likely to be diagnosed with bulimia.
Bulimia Nervosa vs Binge Eating Disorder
Sometimes, bulimia can also be confused with binge eating disorder. Binge eating disorder is another common eating disorder where a person consumes large amounts of food in short time periods, similar to bulimia. The difference between bulimia and binge eating disorder is that people with bulimia also engage in compensatory behaviors like purging, misusing medications, or excessively exercising. These behaviors are an attempt to cancel out the effects of the binge, avoiding weight gain. While people with binge eating disorder often feel guilty or disgusted after bingeing, they do not regularly engage in compensatory behaviors.
Approximately 20-40% of people diagnosed with an eating disorder do not meet full criteria for anorexia or bulimia and are diagnosed with an “Other Specified Feeding or Eating Disorder” (OSFED).6 This diagnosis is reserved for people who clearly present with disordered eating patterns that impair their functioning but fail to meet one of the requirements of the criteria for anorexia, bulimia, or binge eating disorder. An example of a situation where someone with bulimic tendencies may be diagnosed with OSFED is if the binge/purge episodes occur infrequently or if a person purges but does not binge eat.
How to Get Help for Bulimia
If you or someone you care about is suffering from bulimia or you suspect you may have an eating disorder, it is important to seek professional help. Speak with your primary care doctor to get a referral or set up an appointment directly by using an online directory or by contacting your insurance provider. Most of the time, this appointment would be with a licensed counselor, therapist, or psychologist who would confirm a diagnosis and discuss options for further treatment.
It is important to find a therapist who has additional training in treating eating disorders. Specifically, finding a Certified Eating Disorder Specialist (abbreviated as CEDS) is recommended. Professionals with this certification have gone through an extensive training and credentialing process with the International Association of Eating Disorders Professionals Foundation.
In addition to consulting with a therapist, it is also important to follow any recommendations of your primary care doctor for any health complications or concerns and to consult with a registered dietician if recommended to. Usually, the therapist you meet with can help to connect or refer you to these providers, and may ask you to sign a release allowing them to communicate with these professionals to help coordinate your treatment.
Living and Coping with Bulimia
People who have bulimia or any other eating disorder are urged to seek professional treatment. Typically, treatment is needed in order to develop healthier behaviors, and also to address the underlying body image issues that are likely driving the disordered eating patterns. Treatment is also sometimes necessary to address health issues that may have resulted from the long-term use of bingeing, purging, restricting, or misusing laxatives or other medications.
People with eating disorders are at high risk for a range of health problems, even if they are not significantly underweight. Health complications for people with bulimia can be serious and include electrolyte imbalances, lesions in the esophagus, and GI and heart complications.1
In addition to receiving professional help from a dietician, counselor, and/or doctor, some additional steps people with bulimia can take include:
- Instead of counting calories, consider eating intuitively– eating when hungry and stopping when full
- Learn to tell the difference between physical hunger and emotional hunger
- Eat slowly, especially when having foods you typically used to binge-eat
- Be honest with doctors and other care providers about your food and exercise habits and any supplements you are taking
- Monitor and moderate stress and treat any co-occurring mental health conditions
- Limit use of social media/other forms of media exposure if you notice it’s impacting you
- Consider avoiding tracking calories, food intake, weight, or exercise unless you discuss it with professionals involved in your treatment
- Consult with a registered dietician, nutritionist, and other professionals involved in your treatment prior to engaging in diets or exercise routines aimed at weight loss
- Work on improving your body image and expose yourself to people, messages and media that promote body positivity
- Practice mindfulness or develop a meditation routine to work on distancing yourself from unhelpful thoughts that feed into your desire to binge, purge or restrict
Bulimia is a chronic condition, and one that will require ongoing monitoring. Even if you have been in recovery for a prolonged period, watch for signs of relapse, especially during times of high stress. Recovery from bulimia is about working to develop and maintain a healthy relationship with food, and a healthy view of your body. Understand what triggers body image issues or impulses to binge, purge or restrict your intake of food. Be proactive about developing healthy lifestyle routines, a strong support system, and an array of strategies that help you maintain your recovery.
- 30 million Americans suffer from an eating disorder
- Females are five times more likely than males to develop bulimia
- The median age of onset for bulimia is 18
- 1% of people will develop bulimia in the course of their lifetime
- In one study, 35% of people with bulimia reported a history of self-injurious behavior (like cutting)
- Almost 95% of people with bulimia struggle with another mental health condition
- In a study of adolescents, moderate dieters were 5x more likely to develop an eating disorder, and extreme dieters were 18x more likely to develop an eating disorder
Bulimia Quizzes, Tests and Self Diagnosis
Only a licensed health or mental health professional can diagnose an eating disorder. However, there is a screening tool that is helpful in identifying warning signs. The screening tool is called the SCOFF and consists of 5 questions aimed at helping people identify disordered eating patterns.7 Answering yes to one or more of these questions may indicate an underlying eating disorder and should prompt a person to set up an appointment with a doctor, licensed therapist, or other health or mental health professional for a formal assessment.
The five questions on the SCOFF are:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry that you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 lb) in a 3-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?