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12 min read

Bulimia

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What is bulimia?

Bulimia nervosa is an eating disorder and mental health condition.

People who have bulimia try to control their weight by severely restricting the amount of food they eat, then binge eating and purging the food from their body by making themselves sick or using laxatives.

As with other eating disorders, bulimia nervosa can be associated with depression, low self-esteem, misuse of alcohol and self-harm. Learn more about the causes of bulimia nervosa.

Bingeing and purging

Eating disorders are often associated with an abnormal attitude towards food or body image. Everyone has their own eating habits, for example, people with a food intolerance need to avoid eating certain foods to stay healthy. However, people suffering from eating disorders tend to use their eating habits and behaviours to cope with emotional distress and often have an abnormal or unrealistic fear of food, calories and being fat.

Because of this fear, people with bulimia nervosa tend to restrict their food intake. This results in periods of excessive eating and loss of control (bingeing), after which they make themselves sick or use laxatives (purging). They purge themselves because they fear that the bingeing will cause them to gain weight, and usually feel guilty and ashamed of their behaviour. This is why these behaviours are usually done in secret.

Such binge-purge cycles can be triggered by hunger or stress, or are a way to cope with emotional distress.

Warning signs

Signs of bulimia nervosa include an obsessive attitude towards food and eating, an overcritical attitude to their weight and shape and frequent visits to the bathroom after eating, after which the person might appear flushed and have scarred knuckles (from forcing fingers down the throat to bring on vomiting). Read more about the symptoms and warning signs of bulimia.

Who is affected by bulimia nervosa?

As with all eating disorders, women are much more likely to develop bulimia than men. However, bulimia nervosa is becoming increasingly common in boys and men.

Recent studies suggest that as many as 8% of women have bulimia at some stage in their life. The condition can occur at any age, but mainly affects women aged between 16 and 40 (on average, it starts around the age of 18 or 19).

It's estimated that a fifth of the 1.6 million Britons suffering from some form of eating disorder are male.

Bulimia nervosa can affect children, but this is extremely rare.

What to do

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your doctor for a medical check-up and for advice on how to get treatment.

If you think someone you know has bulimia nervosa, talk to them and try to persuade them to see their doctor.

There are also many support groups and charities you can approach for help.

Read about the diagnosis of bulimia.

The first step towards getting better is to recognise the problem and to have a genuine desire to get well.

There's strong evidence that self-help books can be effective for many people with bulimia nervosa, especially if they ask a friend or family member to work through it with them.

If this isn't suitable or is unsuccessful, your doctor can refer you for treatment to an eating disorder service, where you may be offered a structured programme of cognitive behavioural therapy (CBT), as this can help to reduce the urges to binge and vomit.

Read more about the treatment of bulimia.

Signs of bulimia

The main symptoms of bulimia are binge eating and purging (ridding your body of food by making yourself sick or taking laxatives).

Binge eating

Binge eating is repeatedly eating vast quantities of high-calorie food, without necessarily feeling hungry or needing to eat. The urge to eat can begin as an attempt to deal with emotional problems, but can quickly become obsessive and out of control.

Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.

Sometimes, the binges are spontaneous, where you eat anything you can find at that moment. Binge eating episodes can also be planned, where you make a shopping trip to buy foods specifically to binge on.

For more information, read our pages on Binge eating.

Purging

Purging is a response to bingeing. After you've eaten lots of food in a short space of time, you may feel physically bloated and unattractive. You may also feel guilty, regretful and full of self-hatred.

However, the main impulse to purge is a powerful, overriding fear of putting on weight.

The most common methods of purging involve making yourself sick or using laxatives to encourage your body to pass the food quickly.

Less common methods of purging include taking diet pills, over-exercising, extreme dieting, periods of starvation or taking illegal drugs, such as amphetamines.

Cycle of guilt

Bulimia is often a vicious circle. If you have the condition, it's likely you have very low self-esteem. You may also think you're overweight, even though you may be at or near a normal weight for your height and build.

This may encourage you to set yourself strict rules about dieting, eating or exercising, that are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you've denied yourself. After feeling guilty about bingeing, you purge to get rid of the calories.

Other signs of bulimia

Other signs of bulimia can include:

  • regular changes in weight
  • an obsessive attitude towards food and eating
  • large amounts of money being spent on food
  • disappearing soon after eating (usually visiting the toilet to vomit)
  • episodes of over-eating
  • periods of starvation
  • scarred knuckles (from forcing fingers down the throat to bring on vomiting)
  • depression and anxiety
  • unrealistic opinions about body weight and shape
  • isolation

Bulimia causes

There's no simple answer to the question of what causes bulimia. Although the condition is linked to a fear of getting fat, more complex emotions usually contribute to the problem.

The act of bingeing and purging is often a way of dealing with these intense emotions.

Some common factors that may lead to bulimia are outlined below.

Low self-esteem

If you have an eating disorder, you may have a low opinion of yourself and see losing weight as a way of gaining self-worth.

Depression

You may use bingeing as a way of coping with unhappiness. People with bulimia often feel depressed, so they binge regularly. However, purging doesn't relieve this depression and the cycle continues. For more information, see the Health A-Z topic about Depression.

Stress

Bulimia can sometimes occur following stressful situations or life events. For example, you may develop the condition after dealing with a traumatic experience, such as a death or divorce, or during the course of important life-changing events, such as getting married or leaving home.

Bulimia can also occur in people who have experienced physical illness, and in people who have been sexually abused. Some people with bulimia have experienced a difficult childhood, with family problems, arguments and criticism.

Other mental health problems

Bulimia is often linked with other psychological problems. Research shows that bulimia is more common in people who have anxiety disorders, obsessive compulsive disorder, post-traumatic stress disorder and personality disorders.

Cultural and social pressure

Some people believe that the media and fashion industry create pressure for people to aspire to low body weights.

Puberty

Many young people become affected by eating disorders around the time of puberty, when hormonal changes can make them more aware of their body.

If teenagers feel they have no say in their lives, bulimia can seem like the only way they can take control.

Genetics

There may be a genetic factor related to developing bulimia. Research suggests that people who have a close relative who has or has had bulimia are 4 times more likely to develop it than those who do not have a relative with the condition.

Bulimia diagnosis

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your doctor.

This may be a very difficult step for you to take. Most people who have bulimia hide their situation for months or years before seeking help. It can often take a change of situation, such as the start of a new relationship or living with new people, to make a person with bulimia want to seek help.

Once you've explained your situation to your doctor, they'll decide whether to refer you for help from a specialist mental health team. Your local team will include specialist counsellors, psychiatrists, psychologists, nurses, dietitians and other healthcare professionals.

The course of your treatment depends on how serious your condition is and the best way to manage it. Your doctor may recommend a self-help programme to start your recovery before referring you for specialist treatment.

Treatment for bulimia

You can recover from bulimia, but it may be a long and difficult process.

The first step towards getting better is to recognise the problem and to have a genuine desire to get well. This may involve a big change in lifestyle and circumstances.

Treatment usually begins with psychological treatments, aimed to help you re-establish healthy attitudes towards eating. People with bulimia need to explore and understand the underlying issues and feelings that are contributing to their eating disorder, and change their attitudes to food and weight.

Sometimes, your doctor may suggest you try medication, usually in addition to psychological treatment.

Psychological treatment

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is the most common type of psychological treatment for bulimia. It involves talking to a therapist and looking at your emotions in detail to work out new ways of thinking about situations, feelings and food. It may also involve keeping a food diary, which will help determine what triggers your binge eating.

Interpersonal therapy

As with CBT, interpersonal therapy (IPT) involves meeting with a therapist to discuss your condition. However, the focus is more on your personal relationships than your problems with food.

You're more likely to be referred for this type of psychological treatment if you've recently lost a loved one and have experienced a big change in your life. The aim of IPT is to help you establish supportive relationships. This can help draw your focus away from eating.

Medication

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may be used to treat bulimia. The SSRI usually recommended to treat bulimia is called fluoxetine (brand name Prozac).

SSRIs are mainly used to treat depression, but they are also used to treat eating disorders, obsessive compulsive disorder (OCD), anxiety and social phobia.

As with any antidepressant, an SSRI will usually take several weeks before it starts to work. You will usually be started on a low dose, which is then gradually increased as your body adjusts to the medicine.

When you start taking an SSRI, see your doctor after two, four, six and twelve weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it's important that your progress is carefully monitored.

Very few drugs are recommended for children and young people below the age of 18. It's also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.

Hospital treatment

Bulimia is not usually treated in hospital. However, if you have serious health complications and your life is at risk, you may be admitted to hospital. Hospital treatment is also considered if you're at risk of suicide or self-harm.

The recovery process

Once diagnosed, people with bulimia can recover, but it may take a long time. It can be very difficult, both for the person affected and their family and friends.

To recover, someone with bulimia needs to:

  • change their eating habits
  • change the way they think about food
  • gain weight safely, if necessary

The longer someone has had bulimia, the harder it is to re-learn healthy eating habits and gain weight. It's important to start treatment as early as possible, so the person has the best chance of recovery.

For most people, recovery goes through several stages, where progress may involve steps forward and steps back.

Complications of bulimia

There are a number of physical complications associated with bulimia.

These can include any of the following:

  • dental problems. Persistent vomiting can cause your stomach acid to damage the enamel on your teeth, which may lead to tooth decay. Excessive vomiting can also cause bad breath and a sore throat
  • irregular periods. Your menstrual cycle can become unpredictable or even stop altogether. You may also find it difficult to become pregnant in the future
  • poor skin and hair. A lack of nutrients through persistent vomiting or laxative use can make your skin and hair unhealthy. Your skin and hair can become dry and your fingernails can become brittle
  • swollen glands. If you have bulimia, your saliva glands can become swollen from frequent vomiting. This makes your face appear rounder
  • chemical imbalance. Excessive vomiting and laxative use can cause chemical imbalances in your body. This can result in tiredness, weakness, abnormal heart rhythms, kidney damage, convulsions (fits) and muscle spasms
  • bowel problems. Excessive use of laxatives can damage your bowel muscles, resulting in permanent constipation
  • heart problems. Long-term complications of bulimia can include an increased risk of heart problems
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