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Home > Patients & Visitors > Health Library > Bulimia Nervosa
"boo-LEE-mee-uh") is a type of
eating disorder. People with bulimia will eat a larger
amount of food than most people would in a similar situation, in a short period of time (binge). Then, in order to prevent weight gain, they will do something to get rid
of the food (purge). They may vomit, exercise too much, or use medicines like
People who have bulimia judge themselves harshly on their body weight and shape. In order to help them cope with these feelings, they follow a strict diet to try to lose weight. But over time the hunger from the strict diet triggers them to binge eat. After binge eating, they feel out of control, ashamed, guilty, and afraid of gaining weight. This distress
causes them to purge, in hopes of "undoing" any possible weight gain from the binge.
Without treatment, this "binge and purge"
cycle can lead to serious, long-term health problems. Acid in the mouth from
vomiting can cause tooth decay, gum disease, and loss of
tooth enamel. Any type of purging can lead to bone
thinning (osteoporosis), kidney damage, heart problems, or even
If you or someone you know has bulimia or another eating
disorder, get help. Eating disorders can be dangerous. And willpower alone is
not enough to overcome them. Treatment can help a person who has an eating
disorder feel better and be healthier.
All eating disorders are
complex problems, and experts do not really know what causes them. But they may
be caused by a mix of family history, social factors, and personality traits.
You may be more likely to have bulimia if:
Bulimia is most common in:
While bulimia often starts in the teen years, it usually
lasts into adulthood and is a long-term disorder.
People with bulimia:
Any one of these can be a sign of an eating disorder that
anorexia nervosa, another eating disorder. People who
have anorexia eat so little that they become extremely thin. People who have
bulimia may not be thin. They may be a normal size. They may binge in secret
and deny that they are purging. This makes it hard for others to know that a
person with bulimia has a serious problem.
If you are concerned
about someone, look for the following signs. A person may have bulimia if
he or she:
Bulimia can be treated with
psychological counseling and sometimes medicines, such as antidepressants. The
sooner treatment is started, the better. Getting treatment early can make
recovery easier and prevent serious health problems.
with a counselor, a person with bulimia can learn to feel better about herself.
She can learn to eat normally again and stop purging.
mental health problems such as depression often happen with bulimia. If a
person has another condition along with bulimia, more treatment may be needed,
and it may take longer to get better.
Eating disorders can take a
long time to overcome. And it is common to fall back into unhealthy ways of
eating. If you are having problems, don't try to handle them on your own. Get
It can be very scary to realize that someone you care about has an eating
disorder. If you think a friend or loved one has bulimia, you can help.
Learning about bulimia:
The cause of
bulimia is not clear, but it probably results from a
combination of genetics, family behaviors,
social values (such as admiring thinness), and other things that can put someone at risk (such as perfectionism).
Your risk for bulimia increases if your parent, sister, or
brother has the condition. But family history may be only part of the cause.
Stressful life events such as moving, divorce, or the death of a loved
one can trigger bulimia in some people.
Many young women, such as
those in college or high school, have unhealthy attitudes toward eating and
toward their bodies. Socially, they may accept and encourage destructive behaviors
like extreme dieting or binge eating and purging. These beliefs and behaviors are
not normal or healthy. They can play a part in developing eating disorders that
need treatment. Women who begin to severely restrict their diets in order to
lose weight are at risk for bulimia.
Bulimia, like all
eating disorders, is a complex physical and psychological condition. Recovery
requires treatment that helps you change your behavior and also deals with the
deeper attitudes and feelings that cause you to binge and purge.
Any of the above symptoms can be a sign of bulimia or
eating disorder that needs treatment. If you or
someone you know has any of these symptoms, talk to a doctor,
friend, or family member about your concerns right away.
and other eating disorders can be hard to diagnose, because people often
keep unhealthy thoughts and behaviors secret and may deny that they have a
problem. Often a person won't get evaluation and treatment until someone else
notices the signs of bulimia and encourages the person to seek the help that he
or she needs.
Common signs that a person may have bulimia are
when the person:
Conditions that commonly occur with bulimia, such as
substance abuse, or
anxiety disorders, can make treatment of bulimia harder. Recovery from bulimia can take a long time. And
relapse is common. If the person feels extremely
discouraged, be sure to tell the doctor immediately so that the person can get
In some cases, people who have an eating disorder
If you or someone you know shows warning signs of suicide,
seek help immediately.
Bulimia is different from
anorexia. People with anorexia have an extremely low body weight. But most people with bulimia are in their normal
weight range. Some people who have anorexia make themselves vomit, but this is
eating disorder. For more information, see the topic
When you have bulimia, you judge yourself harshly on your body weight and shape. In order to help cope with these feelings, you follow a strict diet to try to lose weight. But over time, the hunger from your diet triggers you to binge eat. Binge eating may also be triggered by a stressful event, when food
gives you a sense of comfort. Feeling guilty and ashamed of binge eating can cause
you to purge to avoid weight gain. This starts the cycle of binging and purging
that becomes a habit.
As bulimia develops, you may not eat at the
beginning of the day. But later you may binge to comfort yourself, especially
at the end of a stressful day.
Vomiting causes the body to release
endorphins, which are natural chemicals that make you feel good.
Eventually you may make yourself vomit even if you have not overeaten so that
you can feel good. Soon you lose control over the binge-purge cycle. Repeated
vomiting, fasting, exercising too much, or misusing
ipecac syrup, or
enemas will eventually cause serious, long-term health
After bulimia becomes a pattern, it is very hard
to return to normal eating without help. Unhealthy eating behaviors can
continue for many years before a person seeks treatment.
treated, bulimia can lead to serious, long-term health problems. It is common
for people to hide the condition from others for years. By the time others
discover the disorder, many people with bulimia already have serious problems.
These range from mild to severe, depending on the type of purging behaviors and
how long they have continued. Health problems caused
by bulimia include:
Overuse of medicine (such as
ipecac syrup) to cause vomiting can lead to diarrhea,
weakness, low blood pressure, chest pain, and trouble breathing. A person
can die from prolonged overuse of these medicines.
health problems often occur along with
bulimia, which may make treatment take longer or make
bulimia harder to treat.1 These conditions
Although bulimia is a long-term disorder linked to serious
health problems, it can be successfully treated. Most people who seek
treatment for bulimia get better. About half of people with bulimia
recover completely with treatment. 2
Although treatment is usually successful, bulimia is a long-term disorder, and
setbacks can occur. A return of symptoms (relapse) might happen. But with ongoing treatment
and patience, most people can eventually overcome bulimia.
among teens with type 1 diabetes is becoming more common. These teens often
lose weight before their diabetes is discovered, then quickly gain weight when
treatment begins. Some learn that they can lose weight by skipping insulin
doses. This causes poor control of their diabetes and can result in serious
problems that can lead to blindness or kidney failure.
The risk for
bulimia or another eating disorder is greatest if a
Call your doctor immediately if you or someone you care about has been
bulimia and now:
Call your doctor to discuss bulimia if you or
someone you care about:
Taking a wait-and-see approach (called watchful
waiting) is not appropriate if you think you or someone you know may have an
eating disorder. Call a doctor or an eating disorder
hotline to discuss your concerns and learn what you can do to help.
Bulimia may be diagnosed and treated by
the following health professionals:
To prepare for your appointment, see the topic Making the Most of Your Appointment.
There is no single
test that can diagnose bulimia or any other eating disorder. But these
illnesses may have a visible effect on your health and eating habits.
If your doctor thinks that you may have an eating disorder, he or she
will check you for signs of problems caused by your diet and purging, such as malnutrition
or electrolyte imbalances. He or she also may ask questions about your mental well-being.
It is common for another mental health problem (such as
obsessive-compulsive disorder) to play a part in an
Common exams and tests for a possible eating
A person can have bulimia and be underweight, average
weight, or overweight. Most people with bulimia are in their normal weight
range. Many binge in secret and deny that they may have a problem. These
factors can make bulimia hard to diagnose.
People with bulimia
often seek medical care for related health concerns, such as
fatigue or stomach problems caused by repeated
Early, accurate diagnosis and treatment of
bulimia can decrease the chances of long-term health problems and even death in
severe cases. Unfortunately, there is no routine screening for eating
disorders. It is common for a person with bulimia to try to hide symptoms,
which can make it hard to detect. Most often a loved one thinks that there
is a problem and seeks help for bulimia. It is common for a person to have
bulimia for a long time and to develop serious health problems before anyone
realizes that the person has the disorder.
psychological counseling and sometimes medicines such
as antidepressants. Treatment does not usually require staying in the hospital,
although this is sometimes needed. Both professional counseling and
antidepressant medicine can help reduce episodes of binging and purging and
help you recover from bulimia. Both are long-term treatments that may require
weeks or months before you notice significant results. You may need treatment
with counseling and possibly medicines for more than a year.
Bulimia that occurs with another condition may take longer to treat. And you
may need more than one type of treatment. If you have another condition that
commonly occurs with bulimia, such as
substance abuse, your doctor may want to treat that
People who seek treatment for bulimia or another
eating disorder may have other health problems caused
by the disorder. If you have had bulimia for a long time without treatment, or
if you have used substances such as laxatives, diuretics, or ipecac syrup to
purge, then you may have a health problem such as
dehydration that needs treatment first. In serious
cases, these conditions related to bulimia may require you to spend time in the
Initial treatment depends how
bulimia is and how long you have had it.
If you have no other conditions that need treatment first, then treatment
for bulimia usually consists of:
The goals of CBT are:
The goals of IPT are:
Continuing treatment will depend
on the how long you have had
bulimia and how severe it is. Continuing treatment
usually consists of:
develop other health problems such as
dehydration or an esophageal tear because of bulimia,
you may need to stay in the hospital or in an
eating disorder treatment facility.
Sometimes people with
bulimia get discouraged because recovery can take a
long time and
relapse is common. If you or the person with bulimia
feels very discouraged or feels
suicidal, call a doctor or other health professional
immediately to get help.
Treatment with an antidepressant
medicine alone may not be enough. Antidepressants work best when combined with psychological counseling.4
Eating disorders are hard to treat.
Recovery may take months to years. The sooner treatment begins, the better the
chance for a full recovery.
Unfortunately, many people don't seek
treatment for mental health problems. You may not seek treatment because you
think the symptoms are not bad enough or that you can work things out on your
own. But getting treatment is important.
If you need help
deciding whether to see your doctor, read about
some reasons why people don't get help and how to overcome them.
There is no known way to prevent
bulimia. Early treatment may be the best way to
prevent the disorder from progressing. Knowing the signs of bulimia and seeking
immediate medical care can help prevent long-term health problems caused by
There are many ways that adults can help children and
teens develop a healthy view of themselves and learn to approach food and
exercise with a positive attitude. Doing this may prevent some children and
teens from developing this disorder.
Home treatment is very important for
people who have
bulimia. You will set individual goals along with your
doctor, registered dietitian, and professional counselor. Some of these goals may
Family members will also need to support the person's goals
for healing. Learning about the disorder will be helpful for the entire
family. Also, show support of a loved one who has bulimia. Offer
support if the person gets discouraged about how long treatment is taking.
Listen to his or her feelings.
Medicines such as antidepressants may
reduce the frequency of the binge-purge episodes of
bulimia. They may also be used to treat other mental
health problems, such as
depression, that often occur along with bulimia. And
you may need antacids to decrease stomach acid or bulk laxatives such as
Citrucel to replace the overuse of more harsh laxatives.
Antidepressant medicines are used to reduce the
frequency of binge-purge cycles and treat any related
Sometimes several antidepressant
medicines are tried before finding the one that works best. Treatment with
medicines is more effective when combined with
psychological counseling, which includes
There is no surgical treatment for
In addition to cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT), several types of
counseling may be useful in treating eating disorders. Other therapies that may be helpful include:
programs that provide self-help materials, such as manuals or computer-based
activities, may be useful in treating eating disorders. But most people who
have an eating disorder also need counseling and possibly medicine.
Although it isn't
part of the treatment of bulimia, relieving stress can help during recovery.
Techniques for managing stress include:
The National Eating Disorders Association (NEDA) is a large
nonprofit organization in the United States dedicated to the prevention of
eating disorders. NEDA helps educate people with eating disorders and their
families about their conditions and also provides information for health
professionals. The organization's Web site will help you locate treatment
referrals for anorexia, bulimia, binge eating disorder, and issues surrounding
body image and weight.
Gwirtsman HE, et al., (2008). Eating
disorders. In MH Ebert et al., eds., Current Diagnosis and Treatment in Psychiatry, 2nd ed., pp. 456–469. New York:
Hay PJ (2010). Bulimia nervosa, search date January 2010. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
American Psychiatric Association (2013). Feeding and eating disorders. In Diagnostic and Statistical Manual of Mental Disorders, 5th ed., pp. 329–354. Washington, DC: American Psychiatric Association.
Yager J, et al. (2006). Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd ed.
Arlington, VA: American Psychiatric Association. Also available
Steering Committee on Practice Guidelines, American Psychiatric Association (2006). Treating Eating Disorders: A Quick Reference Guide. Arlington, VA: American Psychiatric Publishing.
Other Works Consulted
Agras WS (2008). The eating disorders. In DC
Dale, DD Federman, eds., ACP Medicine, section 13, chap.
9. Hamilton, ON: BC Decker.
American Academy of Pediatrics (2010). Clinical report: Identification and management of eating disorders in children and adolescents. Pediatrics, 126(6): 1240–1253.
American Psychiatric Association (2000). Eating
disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 583–595. Washington, DC: American
Anderson AE, Yager J (2009). Eating disorders. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 2128–2149. Philadelphia: Lippincott Williams and Wilkins.
Hay PPJ, et al. (2009). Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews (4).
Mitchell JE, et al. (2013). Biological therapies for eating disorders. International Journal of Eating Disorders, 46(5): 470–477.
Sadock BJ, et al. ( 2007). Bulimia nervosa and eating
disorder not otherwise specified. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th
ed., pp. 735–739. Philadelphia: Lippincott Williams and Wilkins.
Sadock BJ, Sadock VA (2010). Eating disorders. In Kaplan and Sadock's Pocket Handbook of Clinical Psychiatry, 5th ed., pp. 259–268. Philadelphia: Lippincott Williams and Wilkins.
Yager J, et al. (2006). Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd ed.
Arlington, VA: American Psychiatric Association. Also available
November 11, 2013
Kathleen Romito, MD - Family Medicine & W. Stewart Agras, MD, FRCPC - Psychiatry
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