Bulimia nervosa is an eating disorder characterized by episodes of binge eating—consuming a large amount of food very quickly—followed by compensatory behavior, most commonly vomiting or "purging" or the abuse of diuretics or laxatives.
People who are bulimic often feel a lack of control over their behavior. They typically know they have a problem yet often fear they are unable to stop engaging in binges, leading them to engage in purging behaviors in an attempt to avoid weight gain. Binging and purging are often performed in secret, with feelings of shame alternating with relief.
Unlike those with anorexia, people with bulimia are often able to maintain a normal weight for their age; they may even be overweight or obese. But similar to people with anorexia, they tend to fear gaining weight, desperately want to lose weight, and are intensely unhappy with their body size and shape. The binging and purging cycle is usually repeated several times a week. As with anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety, and substance abuse problems. Many physical dysfunctions can result from purging, including electrolyte imbalances, gastrointestinal troubles, and dental problems.
Bulimia nervosa can affect individuals of any race, age, or gender; however, it is significantly more common in women and girls than it is in men and boys. Approximately 3 percent of females have bulimia nervosa during their lifetime, compared to an estimated 1 percent of males. It is more common in adolescents and young adults than in other age groups.
According to DSM-5, common symptoms of bulimia nervosa include:
- Recurrent episodes of binge eating, characterized by eating within a discrete period of time (usually two hours or less) an amount of food substantially larger than most people would eat
- A feeling that one cannot stop eating or control what or how much one eats
- Recurrent compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; and/or excessive exercise
- Self-evaluation unduly influenced by body shape and weight
In addition to behavioral and psychological symptoms, physical symptoms of bulimia nervosa may include:
- Chronically inflamed and sore throat
- Swollen glands in the neck and below the jaw
- Worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acids
- Acid reflux disorder (gastroesophageal reflux disorder, or GERD)
- Intestinal distress and irritation from laxative abuse
- Kidney problems from diuretic abuse
- Severe dehydration from the purging of fluids
- Sores or scabs on the knuckles if hands are used to induce vomiting
Bulimia is categorized as mild, moderate, severe, or extreme based on the number of inappropriate compensatory behaviors that happen each week.
Though many people with bulimia go to great lengths to keep their disorder a secret, there may be several key warning signs that concerned friends and family may notice. Potential red flags include a preoccupation with food, weight, or body size; frequent bathroom trips during or after meals; discomfort with eating in public or eating in front of other people; or a tendency to exercise to excess. Loved ones may also notice physical symptoms such as a swollen face, damaged teeth, sores or scars on the hands or knuckles, or rapidly changing weight.
Many cases of bulimia begin in the late teens and early 20s, though the disorder can go undetected until the 30s or 40s. While late-life eating disorders are less common, it is possible for older adults to develop bulimia nervosa or experience a recurrence of the disorder; one study found that as many as 13 percent of women over age 50 engage in some kind of disordered eating behavior.
Someone with bulimia nervosa may show specific physical signs of the disorder in their face. Regular vomiting may lead to swollen salivary glands which can cause the face and neck to look puffy, a phenomenon sometimes referred to as “bulimia face” or “bulimia cheeks.” They may also have discolored, brittle teeth or painful sores in the corners of their mouth. Intense vomiting may also result in broken veins in the face, which may be visible to observers. Once the individual has stopped purging, puffiness and mouth sores should decrease within a few weeks. Some changes to teeth, however, may not be reversible, although a dentist can help repair broken teeth or fill cavities that resulted from frequent purging.
Russell’s sign—named for British psychiatrist Gerald Russell, who first described bulimia nervosa in the 1970s—refers to calluses or sores that frequently occur on the knuckles of those with the disorder. Because many people with bulimia use their hands and fingers to induce vomiting, they may regularly cut their hands on their incisor teeth. Over time, these small cuts may form into scars or large skin lesions. Because not everyone with bulimia purges by vomiting—and not everyone who vomits uses their hands to do so—Russell’s sign is not universally found among people with bulimia.
While bulimia is not considered as deadly as anorexia, untreated bulimia can indeed be life-threatening and increase the risk of early death. Complications from bulimia can include stomach ruptures, strained esophagus, and heart disease or cardiac arrest, all of which can be deadly. Bulimia also frequently comes with depression and suicidality, and people with bulimia are at increased risk of taking their own life. One study found that, compared to individuals without eating disorders, those with bulimia nervosa had twice the risk of premature death; in comparison, those with anorexia nervosa showed five times greater risk.
There is no single known cause of bulimia, but there are some factors that are thought to play a part in the disorder’s development. These include biological factors such as genes and hormones; eating disorders are thought to have a strong genetic component, and some evidence suggests that hormonal changes that occur during adolescence and midlife may trigger disordered eating behavior, especially in teen girls and perimenopausal women. Other contributing factors include cultural ideals that prioritize and reward thinness, especially in women; a family history of disordered eating, crash dieting, or a familial preoccupation with food and weight; personality traits such as low self-esteem and/or high impulsivity; or major life changes and stressful or traumatic events, such as being sexually assaulted.
A binge can be triggered by stress or other uncomfortable emotions, like anger, sadness, or low self-esteem. It may also occur in response to overly strict dietary restrictions and the feelings of hunger that result. Afterward, purging and other actions to prevent weight gain are typically undertaken to help those with bulimia feel more in control of their eating behavior and to ease the additional stress and anxiety triggered by the binge. Typically, neither binging nor purging offers any lasting relief from negative emotions and often serves to only exacerbate them.
Because bulimia can stem from a combination of factors, there is no known way to consistently prevent it. However, experts suggest that promoting a positive body image and cultivating a healthy relationship with food—at home, at school, and elsewhere—can help children put less stock in cultural messaging that moralizes weight and dietary choices and learn to live peacefully with their bodies. Experts also suggest that regular family mealtimes and the gentle promotion of healthy habits can help children develop a positive relationship with food. Conversely, parents who regularly talk about weight or undergo fad diets may wish to take steps to change their behavior—both for their children’s benefit and for their own.
As with other eating disorders such as anorexia, treatment for bulimia often involves a combination of options and depends on individual needs.
To reduce or eliminate binging and purging, a patient may undergo nutritional counseling and psychotherapy, especially cognitive-behavioral therapy, and be prescribed medication. Some antidepressants—such as fluoxetine (Prozac), the only medication approved by the FDA for treating bulimia—may help patients who also suffer from depression and anxiety. The drug also appears to help reduce binge-eating and purging as well as the chance of relapse, and it can improve eating attitudes.
Cognitive-behavioral therapy tailored to the treatment of bulimia has also been shown to be effective in changing binging and purging behavior and improving attitudes towards eating. Therapy may be done one-on-one or in a group setting.
Eating disorders are complex and challenging, and behavioral, psychological, and neuroscience research on eating disorders is ongoing into causes and treatments. Researchers are also working to define the basic processes involved in the disorders, to understand risk factors, to identify biological markers of the disorder, and to develop medications that target specific pathways affecting eating behavior. Neuroimaging and genetic studies may provide clues for individual responses to specific treatments.
Treatment usually includes a mix of psychotherapy, nutritional support, and sometimes medication, and multiple therapeutic approaches have been used and shown to be effective. Cognitive-behavioral therapy (CBT), family-based treatment (FBT), or interpersonal psychotherapy (IPT) are commonly used to treat bulimia; children and adolescents may be more likely to be treated with FBT, as their recovery often needs to involve other family members to some degree. Psychotherapy for bulimia focuses on the maladaptive thought processes or relationship habits that drive binging and purging, as well as the depression and anxiety that frequently co-occur with bulimia. In nutritional therapy, a dietitian will work with the patient to help them make healthier food choices and learn to better recognize their body’s signals. Medications such as Prozac or other antidepressants can be prescribed for additional symptom support as needed.
Most bulimia treatment can be done in an outpatient capacity. However, in very serious cases or in cases where the physical effects of bulimia have become life-threatening, hospitalization and/or in-patient care may be called for.
How long it takes for the body to recover from the effects of bulimia depends on a few factors, including how long or how frequently the individual engaged in binging and purging; more severe bulimia, or bulimia that was untreated for a longer period of time, will typically result in physical symptoms that take longer to resolve. Some of bulimia's effects, such as swelling of the face and neck or irregular periods, should start to resolve in a few weeks or months into recovery, while others may take years or longer. Some more severe symptoms, such as tooth decay or stomach damage, may unfortunately never resolve on their own; however, dentists or other medical professionals may be able to offer corrective care or help manage lingering side effects or pain.
Because bulimia is such a serious disorder, professional treatment is often paramount to recovery. However, there are many steps that individuals can take on their own to support their treatment and bolster their self-esteem. Identifying common triggers to binging or purging behavior—such as going to the beach or scrolling through social media—and making concrete plans to counteract them can help someone practice healthier habits and prepare for situations where they may be tempted to engage in unhealthy behavior. Getting support from friends, family, or support groups (either in-person or online) can help someone in recovery from bulimia talk through painful feelings, hear others' journeys, and learn additional coping strategies. Practicing self-care—like eating adequate amounts of healthy foods, engaging in regular but not excessive exercise, and prioritizing sleep and rest—can also help, though it may be necessary to discuss food and exercise habits with one’s treatment team in order to avoid slipping back into unhealthy cycles.