Bulimia nervosa: signs and treatments

There’s a lot of pressure in our society to look a certain way and always chase weight loss. The goal of a healthy weight is important for health. When taken to an extreme, though, it can sometimes turn into unhealthy behaviors. The pressure of maintaining a lean body could develop into an eating disorder, such as bulimia nervosa.

Bulimia is a common eating disorder that comes with some serious risks and complications. 

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Bulimia nervosa (often referred to as bulimia) is an eating disorder consisting of binge eating, followed by purging behaviors. People engage in these behaviors in an effort to control their weight. It is most common in young women and girls, often starting at an average of 12 years old (Jain, 2020). 

Bulimia is diagnosed from the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Both sides of the binge-purge cycle must be present. 

Binge eating is:

• Eating portions of food significantly large than most people would consume within a short period

• Loss of control and inability to control eating behaviors

Purging behaviors may include:

• Self-induced vomiting

• Laxative use

• Diuretic use

• Excessive exercise or physical activity

• Fasting

To diagnose bulimia, people must experience at least one episode a week for three months (Jain, 2020). 

People with bulimia may eat normally when they are with other people but secretly binge eat when alone. Then the guilt of overeating leads to purging behaviors. 

It’s crucial to catch the early signs of bulimia because it can lead to severe complications if left untreated. The severity of bulimia is based on the number of times per week that you purge.

People with bulimia are usually average weight, overweight, or have obesity based on BMI, unlike anorexia nervosa, where people are underweight.

Symptoms of bulimia include (Jain, 2020):

• Feeling preoccupied with weight loss or body shape

• Fearing weight gain or obesity

• Repeatedly eating abnormally large amounts of food in a short period, often in secret

• Feeling out of control during binge-eating episodes, like you are unable to control your actions

• Forcing yourself to vomit, excessive exercise, fasting, or using laxatives or diuretics

Other signs of bulimia can include (Jain, 2020):

• Sore throat

• Irregular periods

• Constipation

• Headaches

• Abdominal pain

• Bloating

• Fatigue

• Feeling or appearing uncomfortable eating in public

• Frequently starting restrictive diets

• Low self-esteem

The behaviors used in bulimia can lead to some severe health complications, primarily from purging behaviors.

Self-induced vomiting frequently exposes tissues to stomach acid. Over time, this begins to break down the lining of your esophagus and teeth and causes calluses to appear on the knuckles if the fingers are used to induce vomiting (Jain, 2020).

Laxative abuse can lead to nutrient deficiencies and can even permanently damage your intestines over time (Roerig, 2010). The other types of purging behaviors mentioned (excessive exercising, etc.) could lead to complications, some potentially life-threatening, such as (Mehler, 2015):

• Dehydration and electrolyte imbalances (potassium, phosphorus, sodium)

• Metabolic acidosis

• Acid reflux, sore throat, or esophagus damage

• Ulcers

• Dry skin

• Hair loss

• Tooth decay

• Misuse of drugs or substance abuse

• Heart problems

• Depression or thoughts of self-harm

The exact cause of bulimia is poorly understood. It is likely influenced by many areas, and some of the risk factors include:

• Biology: Genetics and family history appear to play a role in eating disorder development. Being overweight as a child or teen may also increase your risk (Jain, 2020).

• Dieting: Studies show that fasting and restrictive eating could increase the risk of developing binge eating disorder (Stice, 2008). 

• Social, emotional, or psychological issues: Frequent exposure to dieting, cultural body standards, substance use, or having a mental illness could increase your risk of developing an eating disorder (Gunnard, 2012). 

If you are experiencing episodes of uncontrollable eating followed by guilt and the need to “make up for” food consumed, there is support to help you feel better.

Bulimia is driven by body dissatisfaction and mental health. Treatments help to improve your relationship with your body and help you to cope with stress. Talking with your healthcare provider and getting a referral to a mental health professional can help prevent complications of bulimia. 

If you or a loved one are experiencing bulimia, you can get support from the National Eating Disorders Association's helpline. 

Bulimia is treated with medications and psychotherapy.

Currently, fluoxetine (Prozac; see Important Safety Information) is the only FDA-approved medicine to specifically treat bulimia and is effective at decreasing the frequency of bingeing and purging episodes. Other medications, such as other antidepressants, are sometimes recommended to help manage symptoms (Jain, 2020)

Both cognitive-behavioral therapy and interpersonal psychotherapy are effective therapy treatments for people with bulimia (Jain, 2020). 

Therapy helps people to:

• Normalize eating patterns

• Identify and change negative thoughts and beliefs

• Improve body image

• Build emotional coping skills

• Manage stress

• Improve communication skills

• Increase problem solving

For teenagers and adolescents, family-based therapy is recommended to bring their parents or family members into their treatment plan. Involving caregivers helps increase support in the home environment (Hail, 2018).

In addition to mental health professionals, bulimia treatment often includes working with a dietitian trained in eating disorders for nutrition education. They can help you create an eating plan to improve your relationship with food and manage cravings. Eating regularly and not restricting food choices is an important part of bulimia recovery.

With severe bulimia, you may need to be hospitalized to manage the complications that can come from purging. Some people may benefit from inpatient psychiatric treatment for more intensive treatment to start recovering from an eating disorder. 

There is no guaranteed way to prevent bulimia from developing. However, many of the complications can be prevented by getting treatment when you recognize the signs. 

Episodes of binging and purging may come and go throughout your life. Building your coping skills can help to manage stress and potentially prevent relapse of symptoms. 

Focusing on building a good relationship with food and your body may also help. By creating a positive body image and reducing food guilt, you may be less likely to experience binging and purging episodes. 

If you or someone you know is struggling with bulimia, the helpline at the National Eating Disorders Associations is available to connect you to support.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

June 01, 2021

Written by

Ashley Braun, RD, MPH

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.