Bulimia: causes, symptoms and signs, treatment options

Medically reviewed: 8, January 2024

What is bulimia nervosa?

Over 85% of reported cases of bulimia nervosa occur in girls in their late teens and early twenties. On average, Bulimia occurs slightly later than Anorexia Nervosa. Approximately 10% of people with the condition are men.

Bulimia nervosa, medically known as bulimia nervosa, is marked by cycles of binge eating of excessive quantities of food, followed by purging using vomiting, laxatives or diuretics and/or excessive exercising.

Bulimia nervosa is a severe condition characterized by excessive eating followed by attempts to prevent weight gain through methods such as induced vomiting, excessive use of laxatives, over-exercising, or extreme food restriction.

People with bulimia have a distorted body image and an intense fear of becoming fat, even if they are normal weight or underweight. Bulimia can lead to various severe physical and mental health problems, including dental erosion, imbalances in electrolytes, irregular heart rhythms, depression, anxiety, and substance misuse.

The history of bulimia is relatively recent compared to other eating disorders, such as anorexia nervosa. The term bulimia comes from the Greek word for “ox-hunger”, and was first used by the

Roman physician Galen in the 2nd century AD to describe a condition of excessive hunger and thirst. However, Galen’s description did not include the binge-purge cycle that characterizes modern bulimia.In 1979, a British psychiatrist named Gerald Russell wrote the first paper about bulimia. He studied a group of patients who had a serious type of anorexia nervosa.

These patients had episodes of uncontrollable overeating followed by self-induced vomiting or laxative use, and were preoccupied with their weight and shape. Russell coined the term bulimia nervosa to distinguish this disorder from anorexia nervosa, and proposed diagnostic criteria based on the frequency and duration of the binge-purge episodes1.

In 1980, doctors recognized bulimia nervosa as its own type of eating problem. The American Psychiatric Association included it in the third version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). The DSM-III described bulimia nervosa as when people frequently eat a large amount of food in a short time, at least twice a week for three months. They also have a constant worry about their body weight and shape, and they use unhealthy ways to prevent gaining weight. The DSM-III also said there are two types of bulimia nervosa: one where people make themselves throw up or use laxatives, and another where they use different ways to make up for overeating, like not eating or exercising a lot.

Since then, the definition and classification of bulimia nervosa have been revised and refined in subsequent editions of the DSM. The DSM-IV, published in 1994, changed the frequency criterion from twice a week to twice a month, and added the requirement that the binge eating and compensatory behaviors must occur in the absence of anorexia nervosa.

The DSM-5, published in 2013, further changed the frequency criterion from twice a month to once a week, and introduced a severity rating based on the number of episodes per week: mild (1-3), moderate (4-7), severe (8-13), and extreme (14 or more). The DSM-5 also removed the nonpurging subtype, and replaced it with a specifier for the presence or absence of regular use of extreme compensatory behaviors.

If you have bulimia nervosa you are likely to be preoccupied with food. You may have episodes of craving food and eat vast amounts of food in secret. The common foods to binge on are sweet, high-calorie foods often though of as ‘treats’ such as ice cream, cakes, chocolate and biscuits.

The frequency of these bulimic cycles will vary. Some will binge and purge occasionally whilst others will binge and purge several times a day. Some cases of bulimia nervosa are short-lived. However often the symptoms will be present for some months or years before help is sought. Sometimes bulimia persists for many years and in some people symptoms may be present all their lives.

It is difficult to find accurate statistics about bulimia nervosa as it so often goes undiagnosed and untreated. The incidence is usually put at 2-3% of young women but the true incidence may be higher.

Symptoms of bulimia nervosa

The symptoms of bulimia can be divided into two phases: acute and chronic. The acute phase typically takes place within a relatively short timeframe ranging from a few days to a few months following exposure to the bacteria. This phase can persist for a significant duration, spanning from several weeks to several months.

On the other hand, the chronic phase can manifest either immediately after the acute phase or follow a period of inactivity. Its duration is considerably longer, varying from several months to several years, and in some cases, it can persist indefinitely. Furthermore, the chronic phase has the potential to reoccur even after undergoing treatment or experiencing a period of remission.

The acute stage of bulimia presents itself with symptoms resembling those of the flu, including fever, chills, excessive sweating, weakness, fatigue, headaches, reduced appetite, weight loss, and discomfort in the muscles, joints, and back. The fever tends to fluctuate, rising and falling in a consistent daily pattern. The sweats are typically abundant and emit an unpleasant, musty odor. The pain experienced is migratory, meaning it shifts from one area of the body to another.

The severity and duration of these symptoms can vary, and they may either subside on their own or persist for an extended period of time. During the chronic phase of bulimia, individuals experience symptoms that occur repeatedly or persistently, and these symptoms can have an impact on different organs and systems in the body.

The prevalence of complications associated with bulimia is quite high, with several issues commonly observed in individuals struggling with this eating disorder:

1. Repeated vomiting can cause teeth to be exposed to stomach acid which can cause the enamel to wear away. This can lead to tooth decay, sensitivity, discoloration, and pain.
2. Dental erosion can also affect the gums, tongue, and mouth, causing inflammation, infection, and ulcers.
   Electrolyte imbalance: The loss of fluids and minerals during vomiting, laxative use, or excessive exercise can cause an imbalance in the levels of sodium, potassium, calcium, magnesium, and chloride in the blood. It can affect the functioning of the nerves, muscles, and organs, causing symptoms such as muscle cramps, weakness, numbness, tingling, confusion, seizures, and cardiac arrest.
3. Cardiac arrhythmia: Bulimia can make your body lose important nutrients and water, which can make your heart beat in a strange way. This can make you feel heart fluttering, chest pain, trouble breathing, and even pass out. Cardiac arrhythmia can also lead to heart failure, stroke, or sudden death.
4. Depression: The psychological stress, guilt, shame, and isolation caused by bulimia can affect the mood and self-esteem of the person, causing symptoms such as sadness, hopelessness, worthlessness, irritability, and suicidal thoughts. Depression can also affect the appetite, sleep, concentration, and motivation of the person, impairing their daily functioning and quality of life.
5. Anxiety: Bulimia, a psychological disorder characterized by the fear of weight gain, being exposed, or losing self-control, can have detrimental effects on both the nervous system and hormonal balance of an individual. As a result, an array of symptoms may manifest, including feelings of anxiety and restlessness, restlessness, panic, phobia, and obsessive-compulsive behavior. Anxiety can also affect the breathing, heart rate, blood pressure, and digestion of the person, causing physical discomfort and distress.
6. Substance abuse: Bulimia can induce a multitude of negative emotions such as anguish, monotony, and discontent, which in turn can compel individuals to desperately seek solace or refuge by turning to alcohol, drugs, or any other form of substance. Substance abuse can worsen the symptoms and complications of bulimia, as well as cause addiction, dependence, tolerance, withdrawal, and overdose.

Physical symptoms of bulimia are:

• Fluctuations in weight
• Sore throat, heartburn and tooth decay caused by excessive vomiting
• Puffiness of the face caused by swollen salivary glands
• Spots and poor skin condition
• The knuckles bear visible scars as a result of repeated attempts to forcefully push fingers down the throat in an effort to trigger the act of vomiting.
• Irregular periods
• Lethargy and tiredness
• Depression, anxiety, low self esteem and mood swings
• Constipation and intestinal damage.

Other signs:

• Fear of obesity and distorted perception of body weight
• Obsession with eating and episodes of irresistible craving for food and secret bingeing
• Excessive exercise
• Fasting for periods of time
• Using laxatives, diuretics or enemas to counteract the bingeing.
• Tendency to leave the table immediately after a meal and disappearing to the toilet in order to vomit food eaten.

The symptoms of bulimia can be severe and life-threatening, and require immediate medical attention and treatment. The treatment of bulimia involves a multidisciplinary approach that addresses the medical, nutritional, and psychological aspects of the disorder.

What causes bulimia nervosa?

The causes of Bulimia nervosa remain largely unknown but possibilities include:

• Some people who develop this condition have been physically or sexually abused as children.
• Some people have been in difficult family or sexual relationships.
• Others appear not to have experienced these problems but still lack self-worth and need an outlet for their emotions.
• According to recent research findings, it has been indicated that there could potentially exist a connection between genetics and the subject under investigation.
• Social pressures to be thin to be sexually attractive may be a factor.

It is thought that bulimia nervosa is a physical way of dealing with depression, stress, or issues of self-esteem. It may protect you from experiencing feelings and emotions that have become distressing and intolerable.

It enables feelings of short-lived control and calmness but the strategy soon becomes destructive as you begin to feel guilty, disgusted and out of control.

This cycle of bingeing and purging maintains and increases the severity of the condition, which can come to dominate all your emotional experience.

In certain cases, when bulimia is experienced, individuals may also encounter additional issues simultaneously, such as substance abuse, alcohol addiction, self-inflicted harm, theft, and engaging in multiple sexual partners. Also bulimia may be preceded by a brief period of Anorexia Nervosa and weight may remain low.

How to diagnose bulimia nervosa?

The diagnosis of bulimia is based on the clinical presentation, the history of exposure, and the laboratory tests. The laboratory tests include blood tests, urine tests, and electrocardiogram (ECG) to check for electrolyte imbalance, dehydration, kidney function, liver function, and heart function.

The diagnosis may also involve a physical examination, a dental examination, a psychological evaluation, and an eating disorder questionnaire to assess the severity and impact of the disorder.

The diagnosis of bulimia is based on the clinical presentation, the history of exposure, and the laboratory tests.The doctor will check your body, your teeth, how you feel, and ask about your eating habits to understand how serious the problem is. The doctor will use the guidelines in the DSM-5 to see if you have bulimia. The DSM-5 has a list of symptoms to help diagnose bulimia nervosa:

• Repeated episodes of overeating. Binge eating refers to the act of consuming a significant quantity of food within a relatively brief period.
  Eating a lot of food in a short amount of time, more than most people would eat in the same situation.
• Feeling like you can’t stop eating or control how much you eat.
• Repeatedly doing things to stop getting fat, like throwing up, taking too many laxatives or pills, not eating, or exercising too much.
• Engaging in episodes of excessive food consumption and engaging in detrimental behaviors occur approximately once every seven days over a period of three consecutive months.
• Assessing yourself is too much affected by how your body looks and how much you weigh.
• The problem doesn’t only happen during anorexia nervosa episodes.

The DSM-5 also distinguishes between different levels of severity of bulimia nervosa, based on the frequency of the binge-purge episodes per week: mild (1-3), moderate (4-7), severe (8-13), and extreme (14 or more).

The laboratory tests for bulimia include blood tests, urine tests, and electrocardiogram (ECG) to check for electrolyte imbalance, dehydration, kidney function, liver function, and heart function.

The blood tests may measure the levels of sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate, glucose, urea, creatinine, albumin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and thyroid-stimulating hormone.

The urine tests may measure the specific gravity, pH, ketones, and glucose. The ECG may detect abnormalities in the heart rhythm, rate, or conduction.

The physical examination for bulimia may look for signs and symptoms of the disorder, such as:

• weight,
• height,
• body mass index,
• blood pressure,
• pulse,
• temperature,
• skin,
• hair,
• nails,
• eyes,
• mouth,
• throat,
• neck,
• chest,
• abdomen,
• extremities,
• and reflexes.

The dental examination for bulimia may look for signs of dental erosion, such as tooth decay, sensitivity, discoloration, and pain.

The doctor will talk to the person about their eating habits, how they try to lose weight, any physical problems they have, how they feel, how much they like themselves, and how they see their own body. The test for bulimia may ask you questions about your eating habits. It might use specific tests like the Eating Disorder Examination Questionnaire (EDE-Q), the Eating Attitudes Test (EAT), the Bulimia Test-Revised (BULIT-R), or the Binge Eating Scale (BES).

Is it possible to treat bulimia nervosa?

Severity of bulimia nervosa varies considerably. It is likely that there are large numbers of girls with mild symptoms who never seek medical help and do recover on their own. However, there is a risk that the bulimia will slowly get worse with time. A common time for women to seek help is when they are planning to start a family.

Guidelines for the treatment published by the National Institute for Clinical Excellence (NICE) in January 2004 sets the standard for NHS treatment in of eating disorders in England and Wales.

The main guidelines for Bulimia nervosa:

• GP’s should make an early diagnosis of an eating disorder so those seeking help should be assessed and receive treatment at the earliest opportunity.
• Your assessment should be comprehensive and include physical, psychological and social needs.
• Your G.P. should initially offer you an evidence-based self-help programme. In addition to other options, it is recommended that adults who suffer from bulimia nervosa consider incorporating fluoxetine, an antidepressant medication that falls under the category of selective serotonin re-uptake inhibitors (SSRIs), into their treatment plan.

Self help does not work you should be offered Cognitive Behavioral Therapy, especially developed for bulimia (CBT- BN) The course should normally be 16-20 individual sessions over 4 to 5 months.

If you are a teenager with Bulimia you should be offered CBT-BN adapted as needed to suit your age, circumstances and level of development.

Family members (including other children in the family) should be involved as appropriate. The course should normally be 16-20 individual sessions over 4 to 5 months.

If you not respond or do not want CBT, other psychological treatment should be considered.

You will normally be treated in an out- patient setting, however a very small minority of people with bulimia may need inpatient treatment, when the condition is linked to a suicide risk or severe self- harm. Advice can also be sought from specialist eating disorder help lines. You may be encouraged to keep a diary of eating habits. Success often depends on you wanting to recover, if this is the case, the outcome of treatment is very good.

The treatment of bulimia is based on the clinical presentation, the history of exposure, and the laboratory tests. The treatment may also involve a physical examination, a dental examination, a psychological evaluation, and an eating disorder questionnaire to assess the severity and impact of the disorder. The treatment for bulimia follows the rules in the DSM-5, a book by the American Psychiatric Association.

The treatment involves a multidisciplinary approach that addresses the medical, nutritional, and psychological aspects of the disorder. The treatment options include medication, psychotherapy, nutrition therapy, and support groups. The treatment aims to restore the physical and mental health of the person, and to help them develop a healthy relationship with food and body.

Medication for bulimia nervosa

Using medication to treat bulimia is not the main treatment. But in some cases, it can be helpful when used with therapy. The FDA approved fluoxetine (Prozac) as the only medicine to treat bulimia. It is an antidepressant that belongs to a group of medications called selective serotonin reuptake inhibitors (SSRIs).

Fluoxetine may help reduce the frequency and severity of the binge-purge episodes, as well as the symptoms of depression and anxiety that often accompany bulimia. Fluoxetine may also help improve the body image and self-esteem of the person.

Fluoxetine is usually prescribed at a higher dose for bulimia than for depression, and it may take several weeks to show its full effect. Fluoxetine may have some side effects, such as nausea, insomnia, headache, drowsiness, and sexual dysfunction. It may also interact with other medications, such as oral contraceptives, anticoagulants, and antacids. Therefore, it is important to consult with a doctor before taking fluoxetine, and to follow the prescribed dosage and schedule.

Other types of antidepressants, such as sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro), may also be effective for bulimia, but they are not approved by the FDA for this purpose. Antidepressants are rarely prescribed for children or young people under 18 years old, as they may have adverse effects on their growth and development.

Antidepressive medication are not recommended for pregnant or breastfeeding women, as they may harm the baby. Antidepressants should not be stopped abruptly, as they may cause withdrawal symptoms, such as nausea, dizziness, irritability, and anxiety. Antidepressants should be tapered off gradually, under the supervision of a doctor.

Psychotherapy as treatment of Bulimia nervosa

Engaging in therapy, such as seeking guidance and support from a qualified counselor, is widely regarded as the most effective and beneficial approach to address and manage the complex condition known as bulimia. Psychotherapy is when you talk to a mental health professional about bulimia and other problems. This professional could be a therapist, counselor, or psychologist.

Psychotherapy helps the person to understand and change the thoughts, feelings, and behaviors that contribute to the eating disorder, and to cope with the stress and emotions that trigger the binge-purge cycle. Psychotherapy also helps the person to improve their self-image and self-esteem, and to develop a healthy and realistic attitude toward food and weight. Psychotherapy may be conducted individually, in a group, or with the family, depending on the needs and preferences of the person. Psychotherapy may last for several weeks to several months, depending on the severity and duration of the disorder.

Psychotherapy may be delivered in different settings, such as in a clinic, in a hospital, or online.

There are different types of psychotherapy that may be used to treat bulimia, but the most evidence-based and recommended ones are:

Cognitive behavioral therapy (CBT)

Cognitive Behavioral Therapy is a type of psychotherapy that focuses on the relationship between thoughts, feelings, and behaviors. CBT helps the person to identify and challenge the negative and distorted thoughts that underlie the eating disorder, such as the fear of being fat, the obsession with weight and shape, and the perfectionism and self-criticism.

CBT teaches the patient to modify and replace the unhealthy and harmful behaviors that maintain the eating disorder, such as the binge-purge cycle, the dietary restriction, and the excessive exercise.

Cognitive Behavioral Therapy teaches the person to adopt regular and balanced eating patterns, to monitor and record their food intake and emotions, to resist the urge to binge or purge, and to cope with the situations and feelings that trigger the eating disorder. With this therapy a person can enhance their self-esteem and self-acceptance, and to improve their interpersonal and social skills. Cognitive Behavioral Therapy is usually delivered in 16 to 20 sessions, over a period of 4 to 5 months. It may be combined with medication, such as fluoxetine, for better results.

Interpersonal psychotherapy (IPT)

IPT is a kind of therapy that looks at how the relationships you have with others can affect your eating disorder. Interpersonal psychotherapy helps the person figure out and fix problems in their relationships with family, friends, or partners.

Interpersonal psychotherapy also helps the person to improve their communication and problem-solving skills, and to establish and maintain healthy and supportive relationships. IPT assumes that by improving the quality of their interpersonal relationships, the person will also improve their self-image and self-esteem, and reduce their dependence on food and weight as a source of comfort and identity. Interpersonal psychotherapy is usually delivered in 16 to 20 sessions, over a period of 4 to 5 months. IPT may be combined with medication, such as fluoxetine, for better results.

Family-based treatment (FBT)

FBT is a type of psychotherapy that involves the participation of the family members, especially the parents, in the treatment of the eating disorder. Family-based treatment is mainly designed for children and adolescents with bulimia, but it may also be adapted for adults. FBT helps the parents to take an active role in helping their child to recover from the eating disorder, by monitoring and supervising their eating habits, by providing emotional and practical support, and by creating a positive and nurturing family environment.

Family-based treatment also helps the child to regain control over their eating and weight, to develop a healthy and realistic body image, and to cope with the stress and emotions that trigger the eating disorder. FBT makes the family to address and resolve any issues or conflicts that may have contributed to the eating disorder, and to improve their communication and bonding. Family-based treatment  is usually delivered in 15 to 20 sessions, over a period of 6 to 12 months. FBT may be combined with medication, such as fluoxetine, for better results.

Nutrition therapy

Nutrition therapy is a type of treatment that involves working with a dietitian or a nutritionist, who can provide education and guidance on healthy eating and nutrition. This kind of therapy helps the person to understand and correct the misconceptions and myths that they may have about food and weight, such as the effects of calories, fat, carbohydrates, and protein. Doctor helps the person to plan and follow a balanced and varied diet, that meets their nutritional needs and preferences, and that does not trigger the binge-purge cycle.

The goal of the therapy to help the person to establish regular and consistent eating patterns, such as eating three meals and two snacks per day, and avoiding skipping or delaying meals. Patient will learn the person to cope with the hunger and cravings that may arise during the recovery process, and to deal with the fear and anxiety that may be associated with food and eating. Nutrition therapy may be delivered individually, in a group, or online, depending on the availability and suitability of the service.

Support groups

Support groups are a type of treatment that involves meeting and talking with other people who have similar experiences and challenges with bulimia. Patient groups can provide a safe and confidential space for the person to share their feelings and thoughts, to receive and offer feedback and advice, and to give and receive emotional and practical support.

It also helps to achieve a sense of belonging and acceptance, and a source of motivation and inspiration. Such groups can be led by a professional, such as a therapist or a counselor, or by a peer, such as a former or current bulimia sufferer. Meetings can be conducted face-to-face, over the phone, or online, depending on the availability and preference of the service.

Support groups are not a substitute for comprehensive treatment, but they can be helpful as a complement to treatment, or as a follow-up or maintenance service.

Complications of bulimia

In extreme circumstances even if you are of normal weight, you can severely damage your body by frequent binging and purging. Electrolyte imbalance, dangerously low levels of the essential minerals and dehydration can cause heart problems and, occasionally, sudden death due to a heart attack.

They may also cause severe problems to other vital internal organs of the body. In rare instances, binging can cause the stomach to rupture.