Bulimia Nervosa

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Bulimia nervosa facts

  • Bulimia is an eating disorder that is characterized by episodes of binging and purging the food and or associated calories.
  • Bulimia is a significant public-health problem, both because of the physical and mental health effects it can have. This illness often co-occurs with body dysmorphic disorder, depression, anxiety, and substance-abuse disorders.
  • While there is no known specific cause for bulimia, family history and environmental stressors are thought to contribute to the development of the illness.
  • Adolescents are most at risk for developing bulimia, as statistics show that about three-quarters of people who develop the illness do so before they reach 22 years of age, most often at 15 to 16 years of age.
  • Cognitive behavioral therapy is thought to be somewhat superior to other forms of psychotherapy in treating this eating disorder.
  • Medication, nutritional counseling, and family therapy are also often part of the treatment for bulimia.
  • The potential complications of bulimia can be severe and affect virtually every organ system.
  • Only about 45% of people with bulimia fully recover, but recovery is more likely with treatment.

What is bulimia?

Bulimia, also called bulimia nervosa, is one of a number of eating disorders. This mental illness is characterized by episodes of bingeing and somehow purging the food and/or associated calories in the pursuit of weight loss. About 1%-2% of adolescent girls in the United States develop bulimia. While bulimia and other eating disorders tend to occur most often in Caucasian females in this country, males and ethnic minorities are increasingly developing eating disorders. Bulimia is also often co-morbid (co-occurs with) body dysmorphic disorder, which involves the sufferer having a false sense that something is defective with their appearance beyond weight.

Women with eating disorders tend to have higher rates of infertility than women without an eating disorder, in that eating disordered women have lower rates of pregnancy and childbirth. When pregnancy is achieved by women with eating disorders, more than 7% of women suffer from some form of eating disorder during that time, with more than 2% engaging in both bingeing and some form of purging behaviors. Given the changes in body chemistry that such behaviors can cause, bulimia during pregnancy can pose significant health risks for the developing fetus.

This illness is a significant public-health problem both because of the physical and mental-health effects it can have. Bulimia often co-occurs with depression, anxiety, and substance-abuse disorders and results in a loss of productivity due to disability that is higher than that of disability caused by depression and anxiety combined.

Quick GuideEating Disorders: Anorexia, Bulimia, Binge Eating

Eating Disorders: Anorexia, Bulimia, Binge Eating

Drunkorexia, Manorexia, Diabulimia: New Eating Disorders?

In recent weeks, I have read media reports that mentioned both "drunkorexia" and "manorexia." I have fielded questions about "diabulimia" from coworkers and friends. From the sound of these terms, it appears that there are a lot of new and recently discovered eating disorders.

What are causes and risk factors for bulimia?

While there is no known specific cause for bulimia, family history and environmental stressors are thought to contribute to the development of the illness. Generally, while people who have relatives with bulimia are at a higher risk of developing the disorder, this may be as much the result of inherited perfectionism and rigidity as it is an inheritance of the disorder itself. Some life stressors, like family economic problems, can increase the chance of developing bulimia as an adult.

Adolescents are at greatest risk for developing bulimia, as statistics show that about three-quarters of people who develop the illness do so before they reach 22 years of age, most often at 15 to 16 years of age. Adolescents who have any eating problem by 12 years of age are at higher risk for developing bulimia, but children with eating problems as babies are not necessarily at higher risk for getting the illness.

High body mass index, low self-esteem, and being part of a family that is suffering from financial difficulties are risk factors for developing purging behaviors. Involvement in activities that highly reward thinness, like gymnastics, running, wrestling, horse jockeying, or modeling, are other risk factors for developing bulimia.

What are symptoms and signs of bulimia?

Symptoms of bulimia include repeated episodes of bingeing and purging. Binges are defined as uncontrolled episodes of eating food amounts in a short period of time that are clearly more than most people would consume in a similar time period. People with bulimia have trouble controlling their eating during the binges. They also engage in some form of repeated undoing of the excessive food/calories they ingest that occurs during episodes of binge eating. Examples of purging behaviors include making oneself throw up, fasting, excessive exercise, or abuse of laxatives, diet pills, diuretics, or other medications. Bulimic individuals tend to have their self-esteem excessively linked to their appearance in terms of body shape and weight.

Physical signs and symptoms that can be associated with bulimia include sore throat, discolored, deteriorating teeth, and abdominal pain/cramping and bloating associated with repeated vomiting. Individuals with bulimia may develop swollen salivary glands that give the sufferer bigger cheeks. They may also develop constipation, dehydration, dry skin, and thinning hair.

How do physicians diagnose bulimia?

Many providers of health care may help make the diagnosis of bulimia, including licensed mental-health therapists, pediatricians, other primary-care providers, specialists whom you see for a medical condition, emergency physicians, psychiatrists, psychologists, psychiatric nurses, and social workers. One of these professionals will likely conduct or refer the individual with bulimia for an extensive medical interview and physical examination as part of establishing the diagnosis. Bulimia may be associated with a number of other medical conditions, so health-care professionals may perform routine laboratory tests during the initial evaluation to rule out other causes of symptoms.

As part of this examination, a health-care professional may ask the sufferer a series of questions from a standardized questionnaire or self-test to help assess the presence of depression. Thorough exploration for any history or presence of mental-health symptoms will be conducted so that bulimia can be distinguished from other types of eating disorders like anorexia nervosa, binge eating disorder, or pica, or as part of a genetic disorder like Prader-Willi Syndrome. The mental-health professional will also explore whether other forms of mental illness are present.

What is the treatment for bulimia?

Studies on treatment effectiveness for bulimia seem to show that psychotherapy treatment for bulimia is superior to medication or behavior therapy. Cognitive behavior therapy is thought to be somewhat superior to other forms of psychotherapy in treating this eating disorder. This form of psychotherapy helps to alleviate bulimia and reduce the likelihood that it will come back by helping the eating disorder sufferer change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to accomplish these goals:

  • Didactic component: This phase helps to set up positive expectations for therapy and promote the person's cooperation with the treatment process.
  • Cognitive component: This helps to identify the thoughts and assumptions that influence the bulimic individual's behaviors, particularly those that may predispose the sufferer to disordered eating.
  • Behavioral component: This employs behavior-modification techniques to teach the person more effective strategies for dealing with problems.

Family therapy is also often used to treat bulimia, particularly for adolescent sufferers. It usually takes place in three phases:

  • Initially, the family works with the therapist to help the adolescent maintain appropriate food intake and limit negative ways the eating-disordered person uses to control their weight.
  • After the bulimic individual has begun to control their negative eating behaviors, he or she is encouraged to take responsibility for maintaining appropriate eating and refraining from purging behaviors.
  • In the final phase of treatment, more general life issues of the adolescent are addressed and the effects of bulimia on normal activities and normal development are examined.

Nutritional counseling involves teaching the bulimic individual how to diet in a healthy way. It has been found to help decrease the sufferer's tendency to engage in purging behaviors.

Regarding medication treatment of bulimia, fluoxetine (Prozac) has been approved by the U.S. Food and Drug Administration for treatment of this condition. Fluoxetine is a member of the serotonergic antidepressants (SSRIs). Other SSRIs, as well as serotonin/norepinephrine-reuptake inhibitors like venlafaxine (Effexor) and duloxetine (Cymbalta), and tricyclic antidepressants like imipramine (Tofranil) and amitryptiline (Elavil), have also been shown to decrease the binge eating and purging symptoms of bulimia.

SSRIs tend to have fewer side effects than the tricyclic antidepressants (TCAs). Also, SSRIs do not cause orthostatic hypotension (sudden drop in blood pressure when sitting up or standing) and heart-rhythm disturbances like the TCAs do. Therefore, SSRIs are often the first-line treatment for bulimia. Examples of other SSRIs include paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro).

SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a rare but serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances. This condition tends to occur only in very ill psychiatric patients taking multiple psychiatric medications.

The antiepileptic medication topiramate (Topamax) has also been shown to significantly decrease binge eating and is sometimes used to treat people who do not respond to or have intolerable side effects from the other medications.

Quick GuideEating Disorders: Anorexia, Bulimia, Binge Eating

Eating Disorders: Anorexia, Bulimia, Binge Eating

What are complications of bulimia?

The potential dangers of bulimia can be severe and affect virtually every organ system. The malnutrition that can result from inducing vomiting and abusing laxatives, diet pills, and/or diuretics (medications that cause increased urinating) can result in low blood pressure to the point of fainting, cold hands and feet, abnormalities in body chemistry (abnormal electrolyte levels), as well as abnormal hormone levels, failure to ovulate, and delayed puberty. Permanent complications can include stunted growth, decreased bone density, and changes in the person's brain structure. Severe complications can include irregular heartbeat and rectal prolapse. People with bulimia tend to have twice the mortality rates as individuals with no eating disorder. Suicide is a significant component of the higher mortality rate.

What is the prognosis for bulimia?

In contrast to illnesses like depression, that can have as much as a 75% recovery rate, only about 45% of people with bulimia fully recover. Most full recovery takes place between four and nine years later. About 27% of bulimia sufferers significantly improve without full recovery, and more than 20% continue to have chronic symptoms or switch to having another eating disorder.

The mortality rate of bulimia, at 0.3%, is many times less than that of anorexia, which is about 5%. Both of these eating disorders often co-occur with depressive, anxiety, and other mood disorders, as well as with personality disorders like borderline personality disorder.

Is it possible to prevent bulimia?

Most bulimia prevention programs focus on educating the public and at-risk populations like teens about the dangers of the disorder (psycho-education). While psycho-education has been found to increase the knowledge of those who receive it, studies do not show more than minimal change in behavior. More successful than passive psycho-education seems to be prevention approaches that specifically address eating-disordered ways of thinking, like considering thinness as the ideal body type.

Where can one find more information about bulimia?

American Academy of Child and Adolescent Psychiatry
http://www.aacap.org

American Counseling Association
http://www.counseling.org

American Psychiatric Association
http://www.psych.org

American Psychological Association
http://helping.apa.org

National Alliance for the Mentally Ill (NAMI)
2101 Wilson Boulevard, Suite 302
Arlington, VA 22201
HelpLine: 800-950-NAMI [6264]
606-272-7166
http://www.nami.org/

National Association of Social Workers
http://www.naswdc.org

National Mental Health Association
http://www.nmha.org

Quick GuideEating Disorders: Anorexia, Bulimia, Binge Eating

Eating Disorders: Anorexia, Bulimia, Binge Eating

Are there support groups for people with bulimia?

B.E.A.T.-Beating Eating Disorders Support Groups
http://www.b-eat.co.uk

Daily Strength Eating Disorders Support Group
http://www.dailystrength.org

Eating Disorders Anonymous Online Meeting
http://edanonymous.blogspot.com

National Association of Anorexia Nervosa & Associated Disorders
750 E Diehl Road #127
Naperville, IL 60563
Helpline: 630-577-1330

National Association for Males With Eating Disorders-Online Support Groups
Phone: 877-780-0080
Email: Chris@NAMEDinc.org

National Eating Disorders Association
165 West 46th Street, Suite 402
New York, NY 10036
info@NationalEatingDisorders.org
800-931-2237

Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

Bailey, A.P., A.G. Parker, L.A. Colautti, L.M. Hart, P. Liu, and S.E. Hetrick. "Mapping the evidence for the prevention and treatment of eating disorders in young people." Journal of Eating Disorders 2 (2014): 5.

Easter, A., A. Bye, E. Taborelli, F. Corfield, U. Schmidt, J. Treasure, and N. Micali. "Recognising the symptoms: How common are eating disorders in pregnancy?" European Eating Disorders Review 21.4 July 2013: 340-344.

Hafstad, G.S., T. von Soest, and L. Torgersen. "Early childhood precursors for eating problems in adolescence: a 15-year longitudinal community study." Journal of Eating Disorders 1 (2013): 35.

Linna, M.S., A. Raevuori, J. Haukka, J.M. Suvisaari, et al. "Reproductive health outcomes in eating disorders." International Journal of Eating Disorders 46.8 Dec. 2013: 826-833.

Mitchison, D., R. Crino, and P. Hay. "The presence, predictive utility, and clinical significance of body dysmorphic symptoms in women with eating disorders." Journal of Eating Disorders 1 (2013): 20.

Poulsen, S., S. Lunn, S.I.F. Daniel, et al. "A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa." American Journal of Psychiatry 171 (2014): 109-116.

Rosen, D.S. "Identification and management of eating disorders in children and adolescents." Pediatrics 126.6 Dec. 2010: 1240-1253.

Steinhausen, H.C., S. Weber, and P. Cand. "The outcome of bulimia nervosa: findings from one-quarter century of research." American Journal of Psychiatry 166 (2009): 1331-1341.

Stephen, E.M., J. Rose, L. Kenney, et al. "Adolescent risk factors for purging in young women: findings from the national longitudinal study of adolescent health." Journal of Eating Disorders 2 (2014): 1.

Weinstein, J.J. and P.S. Mehler. "Bulimia nervosa." New England Journal of Medicine 349 (2003): 2363-2364.

Yager, J., M.J. Devlin, K.A. Halmi, et al. "Guideline watch: Practice guideline for the treatment of patients with eating disorders, third edition." American Psychiatric Association Practice Guidelines Aug. 2012: 1-18.

Last Editorial Review: 3/16/2016

Reviewed on 3/16/2016
References
Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

Bailey, A.P., A.G. Parker, L.A. Colautti, L.M. Hart, P. Liu, and S.E. Hetrick. "Mapping the evidence for the prevention and treatment of eating disorders in young people." Journal of Eating Disorders 2 (2014): 5.

Easter, A., A. Bye, E. Taborelli, F. Corfield, U. Schmidt, J. Treasure, and N. Micali. "Recognising the symptoms: How common are eating disorders in pregnancy?" European Eating Disorders Review 21.4 July 2013: 340-344.

Hafstad, G.S., T. von Soest, and L. Torgersen. "Early childhood precursors for eating problems in adolescence: a 15-year longitudinal community study." Journal of Eating Disorders 1 (2013): 35.

Linna, M.S., A. Raevuori, J. Haukka, J.M. Suvisaari, et al. "Reproductive health outcomes in eating disorders." International Journal of Eating Disorders 46.8 Dec. 2013: 826-833.

Mitchison, D., R. Crino, and P. Hay. "The presence, predictive utility, and clinical significance of body dysmorphic symptoms in women with eating disorders." Journal of Eating Disorders 1 (2013): 20.

Poulsen, S., S. Lunn, S.I.F. Daniel, et al. "A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa." American Journal of Psychiatry 171 (2014): 109-116.

Rosen, D.S. "Identification and management of eating disorders in children and adolescents." Pediatrics 126.6 Dec. 2010: 1240-1253.

Steinhausen, H.C., S. Weber, and P. Cand. "The outcome of bulimia nervosa: findings from one-quarter century of research." American Journal of Psychiatry 166 (2009): 1331-1341.

Stephen, E.M., J. Rose, L. Kenney, et al. "Adolescent risk factors for purging in young women: findings from the national longitudinal study of adolescent health." Journal of Eating Disorders 2 (2014): 1.

Weinstein, J.J. and P.S. Mehler. "Bulimia nervosa." New England Journal of Medicine 349 (2003): 2363-2364.

Yager, J., M.J. Devlin, K.A. Halmi, et al. "Guideline watch: Practice guideline for the treatment of patients with eating disorders, third edition." American Psychiatric Association Practice Guidelines Aug. 2012: 1-18.

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