Bulimia nervosa, also known as bulimia and binge-purge syndrome, is an eating disorder that is characterized by a pattern of binge eating followed by harmful behaviors to control or prevent any resulting weight gain. Individuals with bulimia tend to associate their self-worth or self-esteem with the way their bodies look, and attempt to control their weight by purging. Bulimia may also be accompanied by abnormalities in mood and perception.
Eating – especially a healthy, well-balanced diet – is necessary for normal functioning of all organ systems. Disordered eating habits (e.g., skipping meals) or prolonged dieting (e.g., calorie restriction) may deplete the body of important nutrients. In some cases, such habits may become chronic and may lead to the development of an eating disorder, such as bulimia.
Binge eating is defined as the consumption of excessive amounts of food in a short time period, usually less than two hours. The food is often high in calories and easy to consume (e.g., ice cream, chips). The binging episodes are also accompanied by a sense of total lack of control. Individuals with bulimia often eat until they are uncomfortably, or even painfully full. Typically, people with bulimia purge themselves of eaten food by self-induced vomiting. The immediate effects of vomiting include relief from physical discomfort caused by the overeating and decrease in fear of gaining weight.
Patients with bulimia may rely on a variety of methods to induce vomiting, including the use of fingers or objects (e.g., pencils) to stimulate the gag reflex. People with bulimia often become so proficient at inducing vomiting, they eventually are able to throw up at will. Other purging methods include the misuse of laxatives (usually mild drugs used for inducing bowel movements) and diuretics. Rarely, people with bulimia rely on emetics (e.g., syrup of ipecac) to induce vomiting or enemas (injecting liquid into the intestines through the anus) for emptying the bowels.
Sometimes people with bulimia may fast for a few days or exercise excessively to compensate for binge eating. They may also rely on diet pills, cigarette smoking, amphetamines and caffeine (e.g., coffee, caffeinated diet drinks) to suppress hunger and/or boost energy. Prolonged use of these agents may result in tolerance and withdrawal symptoms.
Oftentimes, patients with bulimia feel ashamed of the eating problems and attempt to hide their behavior. They frequently eat in secrecy, or as inconspicuously as possible, and may hide food in strange places (e.g., under the bed) for later consumption. Bulimia binges are usually triggered by emotional stress, intense hunger following fasting or feelings related to body weight and shape or food. Following a binge, patients often experience depression and self-disgust.
Patients with bulimia frequently exhibit other types of psychological disorders including clinical depression and anxiety disorders (e.g., obsessive-compulsive disorder), which may also become exacerbated by the bodily effects of the eating disorder. Substance abuse or dependence – especially involving alcohol and stimulant drugs like cocaine (for appetite suppression) – is also prominent among people with bulimia. In severe cases, behavioral and emotional problems associated with this eating disorder may cause suicidal ideation.
Like most eating disorders, bulimia is more prevalent in females than males – especially adolescents and young adults – and is also more common in industrialized, economically developed nations. According to the U.S. National Institute of Mental Health (NIMH), an estimated 1 to 4 percent of females suffer from bulimia during their lifetime. The disorder is more common among males whose occupation or hobbies require gaining and/or losing weight rapidly, such as wrestlers and jockeys. However, because people with bulimia are typically within the normal weight range – although their weight may sometimes fluctuate – it may be difficult for others to recognize there is a problem and the eating disorder is believed to be underreported.
Patients with bulimia may cause bodily harm with frequent episodes of binging and purging. Complications of bulimia include electrolyte imbalance (a loss of vitamins and minerals that are crucial for normal organ functioning, such as potassium) and dehydration (loss of water), which may lead to weakness and irregular heart rhythms. Other complications include teeth and gum decay caused by the acids contained in the vomit and digestive problems including constipation. In rare cases, binge eating may cause the stomach to rupture and chronic purging may result in heart failure and death.
Types and differences of bulimia nervosa
Bulimia nervosa is an eating disorder that is characterized by chronic binge eating followed by harmful dietary habits (e.g., purging, fasting) to prevent any subsequent weight gain. However, bulimia should not to be confused with anorexia nervosa, another eating disorder characterized by chronic, strict calorie restriction and/or purging behaviors. Unlike anorexia nervosa patients, who must weigh more than 15 percent below the expected range for their age and body size, patients with bulimia are almost never underweight.
There are two types of bulimia nervosa:
The most common type of bulimia in which patients regularly engage in purging behaviors to control their weight. The most widely used method is self-induced vomiting. Other purging methods include the misuse of laxatives (usually mild agents that induce bowel movements), diuretics, enemas (injecting liquid into the intestines through the anus to empty the bowels) or emetics (e.g., syrup of ipecac) to induce vomiting.
In this type of bulimia, patients do not engage in purging methods to avoid weight gain. Rather, individuals with nonpurging bulimia follow episodes of binge eating by strict dieting, fasting and/or excessive exercise.
Potential causes and risk factors of bulimia
The exact cause of bulimia nervosa is not thoroughly understood. It occurs more frequently in economically developed nations, which may be due to media portrayals of ideal beauty and attractiveness. These messages often promote thinness as the female ideal. In order to be as thin as some of current pop culture’s celebrities and models, some people strive to maintain a weight that may not be healthy for their bodies. In some cases, though, it is possible to be slender and healthy at the same time. However, it becomes a serious health problem when people use methods detrimental to their body (e.g., purging) to achieve the desired results.
Generally, it is a combination of various factors that may contribute to the development of bulimia nervosa. These include:
Gender. Females are more likely than males to develop bulimia. One reason females may be at greater risk for developing bulimia is their tendency to go on strict diets to achieve the “ideal” (thin) figure, which is often promoted by the media. However, males may also develop this type of eating disorder. According to the U.S. National Institute of Mental Health (NIMH), about 5 to 15 percent of patients with bulimia or anorexia nervosa are male.
Age. Bulimia is more common among adolescents and young adults (people in their 20s and early 30s).
Heredity. Bulimia is more common among people with close family members with bulimia or another eating disorder.
History of chronic dieting and/or anorexia nervosa. Many patients with bulimia report that their eating binges began in the context of or immediately following a diet. Some studies also indicate that many patients with anorexia nervosa later develop bulimia.
History of abuse (e.g., physical, sexual, emotional).
Low self-esteem and feelings of inadequacy or lack of control over one’s life.
Emotional and/or behavioral disorders. Oftentimes, people with bulimia have other mental health disorders including clinical depression and anxiety disorders (e.g., obsessive-compulsive disorder). Generally, the presence of a pre-existing emotional disorder often reinforces the eating disorder and vice versa. Other types of behavioral or emotional problems associated with this eating disorder include substance abuse, and in many cases, suicidal ideation.
Family and social influences. Individuals whose parents, siblings or other close family members and friends are overly critical of their weight, appearance and/or eating habits appear to be at increased risk of developing bulimia.
Competitive sports. People, especially females, who participate in highly competitive athletic activities (e.g., gymnasts, figure skaters, wrestlers, jockeys) may be at greater risk of developing bulimia due to the strict weight requirements of certain sports or performance arts.
Stress. Sometimes, bulimia may be triggered by stressful situations and/or traumatic events including a dysfunctional family, divorce, death of a family member or friend or starting a new school, college or job.
Signs and symptoms of bulimia nervosa
People with bulimia nervosa are typically within the normal weight range – although their weight may sometimes fluctuate – and the purging behavior is often secretive, which may make it difficult for others to initially recognize a problem.
However, the following signs may indicate that a person has bulimia:
Recurrent episodes of binge eating (consuming excessive amounts of food in a short time period)
Extreme efforts to prevent weight gain, especially purging methods (e.g., self-induced vomiting, misusing laxatives [usually mild drugs that induce bowel movement] or diuretics), in addition to fasting or excessive exercising
Repeated trips to the bathroom, especially after eating
Hiding or storing food in strange places (e.g., under the bed)
Unhealthy focus on body shape and weight
Physical symptoms of prolonged bulimia may include:
Dehydration (e.g., very dry skin)
Fatigue or general weakness
Dental problems (e.g., gum and tooth decay) from the gastric acids contained in vomit
Irregular menstrual periods
Swollen cheeks from chronic vomiting
Calluses or scars on knuckles from frequent self-induced vomiting (Russell’s sign)
Frequent sore throats or swollen lymph glands
Signs of trauma to the throat from ongoing use of fingers and/or other objects (e.g., pencils) to induce vomiting
Abdominal pain and other stomach problems including bloating, gas and constipation
Edema (swelling), caused by laxative and diuretic abuse
Painful, swollen veins in the lower portion of the rectum or anus (hemorrhoids)
In addition, patients with bulimia often experience mood or behavioral changes including depression, irritability and insomnia.
Diagnosis of bulimia nervosa
Physicians may diagnose bulimia nervosa based on the patient’s symptoms and eating habits: binge eating and purging cycles that occur at least twice a week for a period of three months or more.
During an initial consultation, a physician will record the patient’s weight and perform a thorough physical examination including:
Checking vital signs, such as heart rate and blood pressure
Evaluation of patient’s skin, abdomen and teeth
Neurological examination to evaluate other potential causes of chronic vomiting, such as a brain tumor
A physician will also compile a comprehensive medical history including family history of physical and psychological disorders (e.g., depression, anxiety disorders) as well as inquire into the patient’s history of dieting and/or eating patterns.
Some of the questions a physician may ask include:
Does the patient’s weight affect their feelings of self-worth?
Does the patient induce sickness (vomiting) because they feel uncomfortably full?
Does the patient worry they have lost control over how much they eat?
Does the patient ever eat in secret?
Does the patient believe that food dominates their life?
In addition, a physician may order diagnostic tests to detect any signs of complications of bulimia including electrolyte imbalance (a loss of vitamins and minerals that are crucial for normal organ functioning, such as potassium), reduced heart rhythms (bradycardia), digestive problems (e.g., constipation) or changes in the menstrual cycle.
Additional diagnostic tests may include:
Laboratory analyses – including a complete blood count (CBC) – of blood samples to measure levels of hormones, enzymes, proteins, electrolytes, vitamins and other substances to assess the function of various organ systems including the liver, kidney, thyroid and pituitary glands as well as the ovaries (female reproductive glands).
Chemical examination of a patient’s urine sample to screen for urinary tract infections, kidney disease and diseases of other organs that result in the appearance of abnormal metabolites (break-down products) in the urine.
This test measures the pattern of electrical impulses generated by the heart. During the procedure, electrodes (devices that detect electrical impulses) are attached to the patient’s chest. The electrical impulses are then recorded on a graph. In patients with bulimia, an EKG can help detect bradycardia and identify the presence of any damage to the heart.
Imaging tests (e.g., x-ray, MRI)
These tests are useful in detecting the presence of any damage in the chest and digestive tract or organs caused by bulimia. For example, an abdominal x-ray may reveal whether bulimia has caused a tear in the esophagus, a severe complication of prolonged bulimia that requires emergency surgery.
After bulimia is diagnosed, a physician may refer the patient for evaluation and supplementary treatment with a mental and/or behavioral health specialist (typically a psychiatrist) and nutritionist (a licensed nutrition expert). A dentist (physician that specializes in dental health) may also be recommended to treat any dental complications resulting from regular self-induced vomiting (e.g., tooth and gum decay).
Treatment options for bulimia nervosa
The sooner an individual with bulimia nervosa is diagnosed and begins treatment, the better the outcome is likely to be. Due to its complexity, bulimia usually requires a comprehensive treatment plan including medical care and monitoring of health complications (e.g., irregular heart rhythms), psychological evaluation and dietary and/or substance abuse counseling. Medical treatment and management of bulimia is the same for both male and female patients.
In severe cases of dehydration, immediate hospitalization of the patient can be necessary to rehydrate (restore loss of water) and restore electrolyte imbalance through intravenous (into a vein [I.V.]) feeding. Emergency medical attention also can be required if severe complications of prolonged bulimia, such as rupturing of the esophagus or heart failure, occur.
Patients with dental problems (e.g., tooth and gum decay) resulting from chronic self-inducing vomiting may be referred to the care of a dentist (dental health specialist) for treatment.
Bulimia nervosa typically requires a multi-disciplinary approach for rehabilitation that may include:
Regular consultation with a nutritionist (licensed nutrition specialist) or registered dietitian is important for patients with bulimia. Nutrition experts may help patients understand the role of adequate nutrition for a healthy body, including the importance of a healthy, well-balanced diet. These specialists also conduct dietary counseling, which can help patients change the nature of their eating behavior. In the case of bulimia, a nutritionist may assist in establishing a pattern of regular, non-binge meals.
These types of mental health therapy will address and help treat psychological disturbances including negative body image, low self-esteem, substance abuse and interpersonal conflicts associated with bulimia as well as the causes that may have led to the development of the eating disorder.
Drug therapy (psychotropic medications, such as antidepressants)
The U.S. Food and Drug Administration (FDA) issued an advisory to healthcare providers to monitor children and adolescents treated with antidepressants for increased suicidal thinking and unusual behaviors.
Patients with bulimia are urged to have regular check-ups with their physician to monitor their overall health and treat any complications, such as bradycardia (reduced heartbeat). Sometimes residential care that involves the patient remaining in a facility that specializes in treating the eating disorder may be necessary, especially in the case of chronic relapses or when patients have not been able to reach a significant degree of medical and psychological stability from their initial treatment plan.
People with bulimia may resist getting and staying in treatment. Family members and other individuals close to the patient are urged to ensure that the person suspected of having bulimia receives needed care and rehabilitation. For some patients, medical treatment may need to be long term.
Prevention methods for bulimia nervosa
Although bulimia nervosa cannot always be prevented, it can be more effectively managed by taking steps that can reduce chances of a relapse, including:
Attending regular follow-up consultations with a primary care physician, psychotherapist and nutritionist to monitor the eating disorder and any related substance abuse
Eating healthy, well-balanced meals
Following a regular schedule of meals
Taking vitamin and mineral supplements
Exercising regularly as recommended by the physician
Getting proper rest and sleep
Engaging in activities that boost self-esteem, such as learning a new skill or hobby or joining a local social group
Setting realistic expectations regarding body and weight (for example, not accepting some media portrayals about ideal body image)
Family members and close peers of people with eating disorders can be a source of help and support by encouraging open communication and healthy eating and dieting habits. People with bulimia may also benefit greatly from participating in support groups to prevent relapse as well as help cope with their condition. Physicians and psychotherapists can provide patients with information regarding support groups for people with bulimia and related substance abuse, if applicable.
Questions for your doctor regarding bulimia
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about bulimia nervosa:
What is your experience and how long have you been treating patients with bulimia nervosa?
Is there a cause or trigger for bulimia?
What are the complications of bulimia?
How is bulimia nervosa diagnosed?
What type of treatment will I need?
How long will the treatment process take?
Will I need to take medications for my eating disorder?
Should I receive therapy? What type of therapy would be best for me?
Are there support groups for people with bulimia?
How can I prevent a relapse?
I have a family member or friend with bulimia nervosa. What are the best ways to help them?
Antidepressants are sometimes helpful.
No restrictions. Don't overexercise to lose weight.
If hospitalization is necessary, intravenous fluids may be prescribed. During recovery, vitamin and mineral supplements will be necessary until signs of deficiency disappear and normal eating patterns are established.
For outpatient therapy, supervision and regulation of eating habits, maintenance of a food diary and reintroduction of feared foods.
Notify your physician if
You have symptoms of bulimia or you suspect your child has bulimia.