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.
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.
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 of the 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 is 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 (see Useful links, above right).
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 is 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 is not 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.
The main symptoms of bulimia are binge eating and purging (ridding your body of food by making yourself sick or taking laxatives).
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 is a response to bingeing. After you have 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 is likely that you have very low self-esteem. You may also think you are overweight, even though you maybe 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, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have 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
There is 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.
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.
You may use bingeing as a way of coping with unhappiness. People with bulimia often feel depressed, so they binge regularly. However, purging does not relieve this depression and the cycle continues. For more information, see the Health A-Z topic about Depression.
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.
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.
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 four times more likely to develop it than those who do not have a relative with the condition.
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 have explained your situation to your doctor, they will 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.
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.
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.
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 are more likely to be referred for this type of psychological treatment if you have 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.
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).
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 is important that your progress is carefully monitored.
Very few drugs are recommended for children and young people below the age of 18. It is also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.
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 are 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 is 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 be involve steps forward and steps back.
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.
Liselle, 38, had bulimia between the age of 14 and 23.
“I was struggling a bit at school and I wasn’t very happy at home. It was classic 'middle-child syndrome', perhaps. As a young woman, I remember feeling very confused about my body.
"I then started to purge my food in the toilet. The secretiveness of it was attractive to me. It was something that was mine. Unfortunately, I became addicted to the habit of vomiting.
"It was something I didn’t have to explain verbally and I think it was a way of feeling in control. I had started to use food for a little bit of comfort. It was a solitary time on my own in the toilet.
"Bulimia is known as the secret disorder. In one way, it’s a coping mechanism. It happens when you can’t cope and something needs to change. That’s why it’s a very dangerous illness to have because you carry on. I carried on in school. I did my exams (I didn’t do very well, but I did them), I got into university and I went abroad for a year. All the time I was secretly vomiting.
"My teeth were decaying and my periods had stopped. I certainly didn’t have any sexual relations, that totally stopped. Unfortunately, I learned to hate myself.
"It was at university that I realised I had to see somebody. I knew it had to stop because I was living a dual life. Apart from seeing a therapist, which I still do, I also went on my own journey of healing using the creative arts. I’m a lecturer and practitioner of community theatre.
"There’s absolutely nothing glamorous, exciting or positive about developing an eating disorder. All it does is decay your body, and it shortens your life. I still spend a ridiculous amount of money on my teeth, which are in a bad way, and it affects fertility. More importantly, it affects how you feel about yourself. It affects your relationships with family, friends and partners. For many years, I didn’t have a relationship because I was too afraid to. I was living in a terribly self-destructive way.
"The difficulty in getting help is that you can’t force people with bulimia to talk about it, particularly with an illness like this. You live in denial and, for me, there was a huge shame about it. I felt that people thought it was grotesque and they didn't want to know about it. You just want to be normal and you want to fit in.
"It’s an addiction. It is not a way of surviving, but the opposite. It's only when you realise that there is something wrong in your behaviour that you want to get help."
Mary, 48, who runs a small business in the Midlands, battled with bulimia for several years but eventually found the road to recovery.
"I think my bulimia may have had its roots in my claustrophobic upbringing. My mother had me when she was very young and was very strict. I never thought it was right to express my feelings and kept them to myself. As a result, I grew up thinking I was never good enough. Even at school, I felt like an outsider.
"I was a normal size 12, but by the time I was 17, I was convinced that I was fat and unglamorous. I started to diet but I just ended up getting larger. I used to starve myself for three or four days, then I would binge on anything I could lay my hands on. This was usually bread, biscuits and cereals. Then I felt so disgusted with myself that I would make myself sick as fast as I could in the hope that I would get rid of the food before I had time to digest it.
"I was still living at home and this was my secret. My parents had no idea what was going on. Even when I went into hospital with a ruptured bile duct from vomiting so much, I managed to explain it away as appendicitis.
"By the time I was 22. I decided to go on a healthy eating regime, which I managed to stick to for two or three years. But then the bulimia started again. I had just come out of a relationship and was feeling pretty low generally. I also felt my life was running away and there was no purpose to it.
"I existed like this until I was about 28, but then I met someone who was a recovering alcoholic who suggested I had an eating disorder. It suddenly dawned on me that my problems weren’t about food, but about my whole attitude to life.
"I decided to look for help and started going to an Overeaters Anonymous (OA) Wednesday-night meeting, which took place about 50 miles from where I lived. It was very helpful and provided a framework for my recovery. But I quickly realised that if I wanted to recover, I had to do it myself.
"I was fed up with feeling sick and tired, so I decided to keep a diary. At the end of each day, I wrote down what had made me feel uncomfortable and the things that had happened that I had tried to soothe with food. As soon as I looked back at what I had written, I realised things weren’t nearly as bad as they seemed. Gradually, I stopped whingeing about things in my diary and started to write about my achievements.
"Slowly, I started to eat normally again and lose weight. I also set up a local OA meeting and have a massive attendance each week. I now feel that I am 99% free of my compulsive eating and I would not dream of vomiting.
"I am healthier now than I have ever been and just so grateful that my bulimia didn’t destroy my looks. The body does heal itself and it's never too late to start on the road to recovery, but you have to take that first step yourself. Nothing is permanent and my recovery process is ongoing every day."
Steve, 55, used to sneak into the kitchen in the middle of the night to eat in secret. He has been a recovering bulimic for 20 years.
“I think the first seeds of bulimia were sewn in 1974. I was an ex-rugby player. I wasn’t a big hairy thing, but I was quite chunky and I used to attract thin women. One day a girlfriend said I was the fattest man she’d ever been out with, and that was that.
“One of the main turning points was in 1980, when I made the transition from being a record company representative to a TV presenter. If you’re bulimic, you really don’t want to be in a position where the camera puts 8lbs on you. One day at lunch, I ate my starter, main course and dessert, followed by a quadruple brandy and I got rid of the lot. I weighed myself when I got home and thought it was fantastic. I could eat and drink whatever I wanted and I didn’t put on any weight. But, of course, it wasn’t fantastic at all.
“I was living in north London with my friend, Maggie, who is now my wife. I wouldn’t eat all day, but I’d sleep-eat at night. Maggie would often get up in the middle of the night and find me wedged in the serving hatch to the kitchen, trying to get something to eat. She started to padlock the serving hatch, but would then wake up to find me cowering over her, begging for the key. We laugh about it now but it was pretty sad.
“I still eat during the night. It’s an odd thing, but somehow it’s allowed because there’s no one around and I feel it’s OK to eat alone. Back then, the situation was bad, but at least I could chat to Maggie about it. I think she probably saved me.
“The thing about addiction is that it never goes. They say an alcoholic takes each day at a time and cigarette smokers are the same. I suppose I take it one day at a time. I still can’t eat big meals in front of other people. I find that really, really hard, and my digestive tract has been badly damaged.
“Bulimia is often referred to as a women’s disease, but I think it’s a people's disease. I just think it may be harder for a man to go to a support group and get up and say, 'Look at me. I’m a bulimic. I throw my food up.'
“For me, nothing beats beat, the eating disorder organisation that I volunteer for. I talk not only about bulimia, but also about myself and what I went through in the hope that it can help other people.
“There is hope and there are people you can talk to. Your situation may seem too big because you build it up, but help is out there. There is light at the end of the tunnel.”