Bulimia nervosa

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 engage in 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. You 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 hard 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 to keep from gaining weight after bingeing
• Misusing laxatives, diuretics or enemas after eating
• Restricting calories or avoiding certain foods between binges
• Using dietary supplements or herbal products excessively for weight loss

When to see a doctor

If you have any bulimia symptoms, seek medical help as soon as possible. If left untreated, bulimia can severely impact your health.

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 get 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 normal weight or 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 foods the person would normally avoid
• 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 factors that could play a role in the development of eating disorders, including biology, emotional health, societal expectations and other issues.

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, parents or children) 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. And, being overweight as a child or teen may increase the risk.
• Psychological and emotional issues. Psychological and emotional problems, such as anxiety disorder or low self-esteem, can contribute to eating disorders. People with bulimia may feel negatively about themselves. Triggers for bingeing can include stress, poor body self-image, food, boredom and restrictive dieting. In some cases, traumatic events and environmental stress may be contributing factors.
• Media and societal pressure. The media, such as TV and fashion magazines, frequently feature a parade of skinny models and actors. These images seem to equate thinness with success and popularity. But whether the media merely reflect social values or actually drive them isn’t clear.
• Sports, work or artistic pressures. Athletes, actors, dancers and models are at a higher risk of eating disorders. Coaches and parents may inadvertently raise the risk 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 or heart failure
• Severe tooth decay and gum disease
• Absent or irregular periods in females
• Digestive problems, and possibly a dependence on laxatives to have bowel movements
• Anxiety and depression
• Misuse of alcohol or drugs
• Suicide

Here’s some information to help you get ready for your appointment, and what to expect from your doctor or other health care provider.

What you can do

Before your appointment, make a list of:

• Your symptoms, even those that may seem unrelated to the reason for your appointment
• Key personal information, including any major stresses or recent life changes
• All medications, herbs, vitamins or other supplements you’re taking, and their doses
• Questions to ask your doctor, so you can make the most of your time together

Ask a family member or friend to come with you, if possible. Someone who accompanies you may remember something that you missed or forgot. A family member may also be able to give your doctor a fuller picture of your home life.

Some questions to ask your doctor or other health care provider include:

• 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 for me?
• How will treatment affect my weight?
• Will my periods begin again?
• Are there any brochures or other printed material I can have? What websites do you recommend?

Don’t hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor or other health care provider will likely ask you several questions, such as:

• How long have you been worried about your weight?
• Do you exercise? If so, how often?
• 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.

If your doctor suspects you have bulimia, he or she will 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 additional tests to help pinpoint a diagnosis, rule out medical causes for weight changes and check for any related complications.

Criteria for diagnosis

For a diagnosis of bulimia, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists these points:

• You recurrently have episodes of eating an abnormally large amount of food ― more than most people would eat in a similar amount of time and under similar circumstances, for example, in a two-hour time period
• You feel a lack of control during bingeing, such as how much you’re eating and whether you can stop eating
• You get rid of the extra calories from bingeing to avoid weight gain by vomiting, excessive exercise, fasting, or misuse of laxatives, diuretics or other medications
• You binge and purge at least once 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

The severity of bulimia is determined by the number of times a week that you purge.

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 health care 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

Psychotherapy, also known as talk therapy or psychological counseling, involves discussing your bulimia and related issues with a mental health provider. Evidence indicates 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
• Family-based therapy 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 that bulimia can have on the teen’s development and the family
• Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills

Ask your mental health provider which psychotherapy he or she will use and what evidence exists that shows it’s beneficial in treating bulimia.

Medications

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 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 bulimia, you may benefit from a medically supervised weight-loss program.

Hospitalization

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 recurrence during 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, 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.
• Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
• Get the right nutrition. 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. Eating regularly and not restricting your food intake is the first step in overcoming bulimia. Talk to your doctor about appropriate vitamin and mineral supplements.
• 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 provider about what kind of physical activity, if any, is appropriate for you, especially if you exercise excessively to burn off post-binge calories.

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 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.

Get support

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 parenting style is not considered a primary cause. It’s best to 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, 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:

• Foster 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.

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