Bulimia, or bulimia nervosa, is a serious and potentially life-threatening psychiatric illness.

It is an eating disorder in which a person binge eats and then tries to compensate by over-exercising and purging, either through vomiting or the use of laxatives.

In the United States (U.S.), 1 percent of young women and 0.1 percent of young men may have bulimia at any one time.

However, numbers are difficult to determine as bulimia, like other eating disorders, is often steeped in secrecy.

Researchers have suggested that bulimia will affect between 1.1 and 4.6 percent of females and between 0.1 and 0.5 percent of males at some time in their life.

It is the most common eating disorder in the U.S.

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Bulimia involves episodes of bingeing on food followed by purging.

The two major symptoms of bulimia nervosa are recurrent bingeing on food, followed by purging, to compensate for the overeating.

Bingeing involves eating large amounts of high-calorie foods in a short time, usually defined as a 2-hour period. The individual may consume up to 3,000 calories or more.

When bingeing starts, it is hard to stop. The person may consume the food so fast that they hardly taste it. They cannot control their behavior.

Bingeing episodes may be spontaneous, or they may be planned, where the individual goes out shopping for specific foods for the binge.

After bingeing, the person feels bloated, unattractive, guilty, ashamed, and regretful. There is a powerful and overwhelming fear of gaining weight.

To compensate, they try to reduce the risk of gaining weight through actions such as self-induced vomiting, over-exercising, fasting or dieting, and overusing diuretics, enemas, or laxatives. They may take amphetamines or other illegal substances.

Purging can lead to serious complications. Moreover, it does not reduce weight and may even contribute to weight gain in the long term.

A vicious cycle of guilt results, due to low self-esteem and feeling overweight, even if the person's weight is normal. The individual may then set themselves strict and unrealistic rules about eating, exercise, or both. When they are unable to maintain these goals, another binge occurs.

A person with bulimia nervosa is most likely of normal weight or slightly overweight. It can be difficult to notice the signs and symptoms because the person will try hard to hide them.

Behavioral indications of bulimia include:

  • an obsession with eating and food
  • eating alone
  • the sudden disappearance of food, or the appearance of many wrappers in the trash
  • a lot of money spent on food
  • leaving the room after eating, normally to visit the bathroom
  • hiding or hoarding food
  • compulsive exercising
  • constantly complaining about being overweight
  • going through phases of fasting or saying they are not hungry, and then eating too much

Pills may be hidden away, including laxatives, diuretics, diet pills, and emetics, a drug to induce vomiting. Drug packaging may appear in the trash.

Physical signs include:

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Purging can lead to serious complications, including damage to the esophagus.
  • severe dehydration
  • nutritional deficiencies, leading to poor health
  • changing body weight
  • scars on the knuckles, known as "Russell's Sign," where fingers are forced down the throat to induce vomiting
  • acid reflux disorder
  • chronic sore or inflamed throat and damaged teeth, due to the acidity in the vomit
  • swollen cheeks, due to damage to the parotid glands
  • irregular menstruation
  • broken blood vessels in the eyes

Friends or family may notice that the person withdraws from their usual activities and that they show signs of mood swings, and possibly anxiety and depression. Interpersonal conflicts may occur. The person may lie to cover up their behavior.

The patient is usually aware that they have a problem, but they may be too ashamed or unable to tell anyone about it.

Treatment is long term. Ideally, it combines psychotherapy, family therapy, nutrition counseling, and medication.

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Many people who seek treatment recover from bulimia.

It is essential for the patient to accept their need for treatment, and agree to co-operate and participate. Some patients resist treatment, while others may fluctuate in their adherence.

Stressful life events may trigger relapses.

Behavioral and cognitive therapy can help patients:

  • understand why they have the disorder, and which feelings, behaviors, and thoughts are contributing to it
  • change their perception of appearance, body weight, food, and eating

Support from family and friends is key to effective and long-term positive outcomes.

The patient's family needs to understand what bulimia nervosa is and to identify its signs and symptoms rapidly. Family therapy can help in the healing process.

Interpersonal therapy focuses on social roles and relationships. Patients learn new ways to manage conflicts with friends or family and to improve these relationships.

Medications can help with depression. Fluoxetine, also known as Prozac, is approved by the U.S. Food and Drug Administration (FDA) for use in bulimia nervosa.

Nutritional counseling can help break the cycle of bingeing and compensation. Patients learn to structure and pace their meals, and to set calorie goals that match their needs.

Hospitalization is rarely needed unless there is a risk of suicide or self-harm.

The University of Maryland Medical Center (UMM) suggest that the following complementary treatments may help:

  • Avoiding caffeine, alcohol, and tobacco, and drinking 6 to 8 glasses of water a day
  • Taking supplementary vitamins and minerals, after discussing with a physician
  • Using herbs that boost overall health, such as holy basil and catnip
  • Massage to reduce stress

Any complementary therapy should first be discussed with the doctor

Bulimia nervosa can have a range of possible effects on the body.

These include:

  • imbalanced levels of electrolytes, which can lead to heart problems, including palpitations and heart failure
  • gastric rupture, which can occur during bingeing
  • tooth staining and decay from frequent vomiting
  • chronic bowel issues, including irregular movements and constipations, as a result of taking laxatives in a way that is not medically advised
  • peptic ulcers
  • pancreas infections

For people with bulimia, their eating behaviors and habits are a way of coping with emotional stress. They tend to have an irrational fear of becoming fat, of calories, and of food.

They may have other challenges too, for example, depression, anxiety, and a tendency to engage in self-harm, impulsive behavior, and substance abuse.

Bulimia starts as a way of coping with emotional problems, but it becomes an obsession that the patient cannot control.

Contributing factors

The exact cause is unknown, but researchers believe it stems from a combination of genetic, biological, psychological, social, and behavioral factors.

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Bulimia is linked to a fear of weight gain, but the underlying factors are more complex than that.

The National Institute of Mental Health (NIMH) note that it seems to run in families. They suggest that genetic studies may provide more information in future.

Bulimia is linked to a fear of getting fat, but the underlying problem normally relates to emotional and mental health.

Brain imaging technology has shown differences in brain response between women with bulimia and those without when shown pictures of slim women and food.

Conditions associated with bulimia include depression, anxiety, stress, personality disorders, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).

Eating disorders often emerge in puberty, a time of major hormonal changes and growing awareness of the body. Findings from a 2007 study suggest that changes in ovarian hormones may increase the risk.

Environmental factors may include:

  • Exposure to unhelpful role models through the media and the fashion industry
  • Pressures of sport and other physical activity, especially those that emphasize weight

Early diagnosis improves the chances of a good outcome, but diagnosis can be challenging. The individual may do everything possible to hide their condition, and their weight can be normal.

A primary care physician will start by asking the patient about their mental and physical health, lifestyle, and medical history, and by carrying out a physical examination.

Diagnostic tests can help rule out other underlying diseases or conditions.

If the doctor suspects bulimia nervosa, they may refer the patient to a mental health specialist.

According to the DSM-5, to be diagnosed with bulimia nervosa, the patient must meet the following criteria:

  • Recurrent episodes of binge eating that the patient feels unable to control.
  • Purging the excess intake by vomiting, fasting, over-exercising, and misusing laxatives, diuretics, enemas, and other drugs.
  • Bingeing and purging have been taking place at least once a week during the last 3 months.
  • The patient's feeling of self-worth is influenced too much by their body shape and weight.
  • This behavior is not related to anorexia nervosa.

Some patients do not meet all these criteria, but they may still have some kind of eating disorder.

Early treatment improves the chance of recovery.

Complications can arise if the person does not receive treatment. These can lead to other serious, and possibly fatal, conditions.

Physical problems include:

  • swollen fingers, caused by overuse of laxatives
  • gingivitis, or inflammation of the gums
  • inflammation of the esophagus
  • swelling of salivary glands, near the cheeks
  • irregular menstruation

Damage to the bowel muscles can lead to chronic constipation. Repeated vomiting can cause dehydration, increasing the risk of kidney damage and kidney stones.

A chemical imbalance can result from excessive purging.

This can cause:

  • tiredness
  • muscle spasms
  • convulsions
  • kidney damage
  • poor skin and hair, and brittle nails
  • arrhythmia, or abnormal heart rhythms, and possibly heart failure

Without treatment, mental health problems can persist, including the possibility of anxiety, depression, OCD, and substance abuse.

Outlook

The Harvard Medical School notes that about 1 in 4 patients recover without treatment and that more than half get better with treatment. They also encourage ongoing followup, as relapses are possible.