Bulimia Nervosa

Bulimia nervosa, commonly called bulimia, is a serious, potentially life-threatening eating disorder. People with bulimia may secretly binge — eating large amounts of food with a loss of control over the eating — and then purge, trying to get rid of the extra calories in an unhealthy way. To get rid of calories and prevent weight gain, people with bulimia may use different methods. For example, you may regularly self-induce vomiting or misuse laxatives, weight-loss supplements, diuretics or enemas after bingeing. Or you may use other ways to rid yourself of calories and prevent weight gains, such as fasting, strict dieting or excessive exercise. If you have bulimia, you’re probably preoccupied with your weight and body shape. You may judge yourself severely and harshly for your self-perceived flaws. Because it’s related to self-image — and not just about food — bulimia can be hard to overcome. But effective treatment can help you feel better about yourself, adopt healthier eating patterns and reverse serious complications.

SYMPTOMS

Bulimia signs and symptoms may include:

  • Being preoccupied with your body shape and weight
  • Living in fear of gaining weight
  • Repeated episodes of eating abnormally large amounts of food in one sitting
  • Feeling a loss of control during bingeing — like you can’t stop eating or can’t control what you eat
  • Forcing yourself to vomit or exercising too much to keep from gaining weight after bingeing
  • Using laxatives, diuretics or enemas after eating when they’re not needed
  • Fasting, restricting calories or avoiding certain foods between binges
  • Using dietary supplements or herbal products excessively for weight loss

The severity of bulimia is determined by the number of times a week that you purge, usually at least once a week for at least three months.

When to see a doctor

If you have any bulimia symptoms, seek medical help as soon as possible. If left untreated, bulimia can severely impact your health. Talk to your primary care provider or a mental health professional about your bulimia symptoms and feelings. If you’re reluctant to seek treatment, confide in someone about what you’re going through, whether it’s a friend or loved one, a teacher, a faith leader, or someone else you trust. He or she can help you take the first steps to get successful bulimia treatment.

Helping a loved one with bulimia symptoms

If you think a loved one may have symptoms of bulimia, have an open and honest discussion about your concerns. You can’t force someone to seek professional care, but you can offer encouragement and support. You can also help find a qualified doctor or mental health professional, make an appointment, and even offer to go along. Because most people with bulimia are usually normal weight or slightly overweight, it may not be apparent to others that something is wrong. Red flags that family and friends may notice include:

  • Constantly worrying or complaining about being fat
  • Having a distorted, excessively negative body image
  • Repeatedly eating unusually large quantities of food in one sitting, especially foods the person would normally avoid
  • Strict dieting or fasting after binge eating
  • Not wanting to eat in public or in front of others
  • Going to the bathroom right after eating, during meals or for long periods of time
  • Exercising too much
  • Having sores, scars or calluses on the knuckles or hands
  • Having damaged teeth and gums
  • Changing weight
  • Swelling in the hands and feet
  • Facial and cheek swelling from enlarged glands

CAUSES

The exact cause of bulimia is unknown. Many factors could play a role in the development of eating disorders, including genetics, biology, emotional health, societal expectations and other issues.

RISK FACTORS

Girls and women are more likely to have bulimia than boys and men are. Bulimia often begins in the late teens or early adulthood.

Factors that increase your risk of bulimia may include:

  • People with first-degree relatives (siblings, parents or children) with an eating disorder may be more likely to develop an eating disorder, suggesting a possible genetic link. Being overweight as a child or teen may increase the risk.
  • Psychological and emotional issues. Psychological and emotional problems, such as depression, anxiety disorders or substance use disorders are closely linked with eating disorders. People with bulimia may feel negative about themselves. In some cases, traumatic events and environmental stress may be contributing factors.
  • People who diet are at higher risk of developing eating disorders. Many people with bulimia severely restrict calories between binge episodes, which may trigger an urge to eat again and then purge. Other triggers for bingeing can include stress, poor body self-image, food and boredom.

COMPLICATIONS

Bulimia may cause numerous serious and even life-threatening complications. Possible complications include:

  • Negative self-esteem and problems with relationships and social functioning
  • Dehydration, which can lead to major medical problems, such as kidney failure
  • Heart problems, such as an irregular heartbeat or heart failure
  • Severe tooth decay and gum disease
  • Absent or irregular periods in females
  • Digestive problems
  • Anxiety, depression, personality disorders or bipolar disorder
  • Misuse of alcohol or drugs
  • Self-injury, suicidal thoughts or suicide

PREVENTION

Although there’s no sure way to prevent bulimia, you can steer someone toward healthier behaviour or professional treatment before the situation worsens. Here’s how you can help:

  • Foster and reinforce a healthy body image in your children, no matter what their size or shape. Help them build confidence in ways other than their appearance.
  • Have regular, enjoyable family meals.
  • Avoid talking about weight at home. Focus instead on having a healthy lifestyle.
  • Discourage dieting, especially when it involves unhealthy weight-control behaviours, such as fasting, using weight-loss supplements or laxatives, or self-induced vomiting.
  • Talk with your primary care provider. He or she may be in a good position to identify early indicators of an eating disorder and help prevent its development.
  • If you notice a relative or friend, who seems to have food issues that could lead to or indicate an eating disorder, consider supportively talking to the person about these issues and ask how you can help.

DIAGNOSIS

If your primary care provider suspects you have bulimia, he or she will typically:

  • Talk to you about your eating habits, weight-loss methods and physical symptoms
  • Do a physical exam
  • Request blood and urine tests
  • Request a test that can identify problems with your heart (electrocardiogram)
  • Perform a psychological evaluation, including a discussion of your attitude toward your body and weight
  • Use the criteria for bulimia listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Your primary care provider may also request additional tests to help pinpoint a diagnosis, rule out medical causes for weight changes and check for any related complications.

TREATMENT

When you have bulimia, you may need several types of treatment, although combining psychotherapy with antidepressants may be the most effective for overcoming the disorder. Treatment generally involves a team approach that includes you, your family, your primary care provider, a mental health professional and a dietitian experienced in treating eating disorders. You may have a case manager to coordinate your care. Here’s a look at bulimia treatment options and considerations.

Psychotherapy

Psychotherapy, also known as talk therapy or psychological counselling, involves discussing your bulimia and related issues with a mental health professional. Evidence indicates that these types of psychotherapy help improve symptoms of bulimia:

  • Cognitive behavioural therapy to help you normalise your eating patterns and identify unhealthy, negative beliefs and behaviours and replace them with healthy, positive ones
  • Family-based treatment to help parents intervene to stop their teenager’s unhealthy eating behaviours, to help the teen regain control over his or her eating, and to help the family deal with problems that bulimia can have on the teen’s development and the family
  • Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills

Ask your mental health professional which psychotherapy he or she will use and what evidence exists that shows it’s beneficial in treating bulimia.

Medications

Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI), which may help even if you’re not depressed. 

Nutrition education

Dietitians can design an eating plan to help you achieve healthy eating habits to avoid hunger and cravings and to provide good nutrition. Eating regularly and not restricting your food intake is important in overcoming bulimia. 

Hospitalization

Bulimia can usually be treated outside of the hospital. But if symptoms are severe, with serious health complications, you may need treatment in a hospital. Some eating disorder programs may offer day treatment rather than inpatient hospitalisation.

Treatment challenges in bulimia

Although most people with bulimia do recover, some find that symptoms don’t go away entirely. Periods of bingeing and purging may come and go through the years, depending on your life circumstances, such as recurrence during times of high stress. If you find yourself back in the binge-purge cycle, follow-up sessions with your primary care provider, dietitian and/or mental health professional may help you weather the crisis before your eating disorder spirals out of control again. Learning positive ways to cope, creating healthy relationships and managing stress can help prevent a relapse. If you’ve had an eating disorder in the past and you notice your symptoms returning, seek help from your medical team immediately.

LIFESTYLE AND HOME REMEDIES

In addition to professional treatment, follow these self-care tips:

  • Stick to your treatment plan. Don’t skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
  • Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
  • Get the right nutrition. If you aren’t eating well or you’re frequently purging, it’s likely your body isn’t getting all of the nutrients it needs. Talk to your primary care provider or dietitian about appropriate vitamin and mineral supplements. However, getting most of your vitamins and minerals from food is typically recommended.
  • Stay in touch. Don’t isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart and that nurturing, caring relationships are healthy for you.
  • Be kind to yourself. Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
  • Be cautious with exercise. Talk to your primary care provider about what kind of physical activity, if any, is appropriate for you, especially if you exercise excessively to burn off post-binge calories.

ALTERNATIVE MEDICINE

Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with eating disorders. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications. Weight-loss and other dietary supplements don’t need approval by the Food and Drug Administration (FDA) to go on the market. And natural doesn’t always mean safe. If you choose to use dietary supplements or herbs, discuss the potential risks with your primary care provider.

COPING AND SUPPORT

You may find it difficult to cope with bulimia when you’re hit with mixed messages from the media, culture, coaches, family, and maybe your friends or peers. So how do you cope with a disease that can be deadly when you’re also getting messages that being thin is a sign of success?

  • Remind yourself what a healthy weight is for your body.
  • Resist the urge to diet or skip meals, which can trigger binge eating.
  • Don’t visit websites that advocate or glorify eating disorders.
  • Identify troublesome situations that trigger thoughts or behaviours that may contribute to your bulimia, and develop a plan to deal with them.
  • Have a plan in place to cope with the emotional distress of setbacks.
  • Look for positive role models who can help boost your self-esteem.
  • Find pleasurable activities and hobbies that can help distract you from thoughts about bingeing and purging.
  • Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement.

Get support

If you have bulimia, you and your family may find support groups helpful for encouragement, hope and advice on coping. Group members can truly understand what you’re going through because they’ve been there. Ask your doctor if he or she knows of a group in your area.

Coping advice for parents

If you’re the parent of someone with bulimia, you may blame yourself for your child’s eating disorder. But eating disorders have many causes, and parenting style is not considered a cause. It’s best to focus on how you can help your child now. Here are some suggestions:

  • Ask your child what you can do to help. For example, ask if your teenager would like you to plan family activities after meals to reduce the temptation to purge.
  • Allow your child to express feelings.
  • Schedule regular family mealtimes. Eating at routine times is important to help reduce binge eating.
  • Let your teenager know any concerns you have. But do this without placing blame.

Remember that eating disorders affect the whole family, and you need to take care of yourself, too. If you feel that you aren’t coping well with your teen’s bulimia, you might benefit from professional counselling. Or ask your child’s primary care provider about support groups for parents of children with eating disorders.

PREPARING FOR YOUR APPOINTMENT

Here’s some information to help you get ready for your appointment, and what to expect from your health care team. Ask a family member or friend to go with you, if possible, to help you remember key points and give a fuller picture of the situation.

What you can do

Before your appointment, make a list of:

  • Your symptoms, even those that may seem unrelated to the reason for your appointment
  • Key personal information, including any major stresses or recent life changes
  • All medications, vitamins, herbal products, over-the-counter medications or other supplements you’re taking, and their dosages
  • Questions to ask your doctor so that you can make the most of your time together

Some questions to ask your primary care provider or mental health professional include:

  • What kinds of tests do I need? Do these tests require any special preparation?
  • What treatments are available, and which do you recommend?
  • Is there a generic alternative to the medicine you’re prescribing for me?
  • How will treatment affect my weight?
  • Are there any brochures or other printed material I can have? What websites do you recommend?

Don’t hesitate to ask other questions during your appointment.

Credit: Mayo Clinic Staff, 10 May 2018.