Bulimia Nervosa

What bulimia nervosa involves

The diagnosis requires:

1. Recurrent binge eating: eating, in a discrete period (for example 2 hours), an amount clearly larger than most people would, with a sense of loss of control.
2. Recurrent compensatory behaviors to prevent weight gain: self-induced vomiting, laxatives, diuretics, fasting, or excessive exercise.
3. Both occurring on average at least once a week for 3 months.
4. Self-evaluation unduly influenced by body shape and weight.
5. Not occurring only during episodes of anorexia nervosa.

Severity is based on the weekly number of compensatory episodes: mild (1 to 3), moderate (4 to 7), severe (8 to 13) and extreme (14 or more).

Signs and symptoms

Behavioral signs

• going to the bathroom right after meals
• large amounts of food disappearing, hidden food or wrappers
• laxative, diuretic or diet pill packets
• strict dieting between binges, skipping meals
• rigid exercise routines, exercising despite illness or injury
• secrecy about eating, avoiding eating with others
• frequent weighing or body checking, or avoiding mirrors

Physical signs

• swollen cheeks and jaw (enlarged salivary glands)
• calluses or scars on the backs of the knuckles (Russell's sign) from inducing vomiting
• tooth erosion, sensitivity and cavities from stomach acid
• sore throat, hoarse voice, acid reflux
• bloating, constipation, abdominal pain
• weight fluctuations, usually within or above the normal range
• irregular or absent periods
• tiredness, dizziness and fainting
• dry skin and brittle hair

Emotional signs

• intense fear of gaining weight
• feelings of shame, guilt and disgust after binges
• low self-esteem, mood swings, anxiety and depression
• self-harm or substance use in some people

Bulimia vs other eating disorders

Causes and risk factors

Bulimia arises from a mix of factors:

• Genetics: eating disorders, depression and anxiety in the family
• Dieting: strict dieting often precedes and drives the binge-purge cycle
• Psychological factors: perfectionism, low self-esteem, impulsivity, difficulty managing emotions
• Life events: trauma, abuse, bullying (especially about weight), major stress
• Social pressures: appearance-focused sports and professions, social media and weight stigma
• Other mental health conditions: depression, anxiety, substance use disorders

Health effects of bulimia

• Electrolyte imbalance: vomiting and laxatives lower potassium (hypokalemia), chloride and magnesium, which can cause weakness, cramps, heart rhythm problems and sudden death.
• Dehydration and kidney problems.
• Digestive damage: esophagitis, Mallory-Weiss tears, rarely esophageal rupture. Laxative misuse can lead to dependence and chronic constipation.
• Dental erosion: enamel loss, sensitivity and decay. See dental erosion.
• Swollen salivary glands.
• Menstrual and fertility problems.
• Mental health: depression, anxiety and a raised risk of suicide.

Diagnosis

A doctor or mental health professional will ask about eating patterns, binges, purging, exercise, weight history and mood. Screening questionnaires such as SCOFF can help. Physical assessment includes:

• weight, heart rate, blood pressure (lying and standing), temperature
• dental and throat examination
• blood tests: potassium, sodium, chloride, bicarbonate, magnesium, phosphate, kidney function, blood count and glucose
• an ECG if electrolytes are abnormal or there are heart symptoms

Treatment

Psychological therapy

• CBT for eating disorders (CBT-ED): the first-line treatment for adults. It addresses regular eating, breaking the binge-purge cycle, and concerns about shape and weight. Typically 20 sessions or more. Guided self-help based on CBT is an option to start.
• Family-based treatment: recommended for children and teenagers, involving parents in supporting recovery.
• Interpersonal therapy and dialectical behavior therapy for some people.

Medicine

• Fluoxetine at higher doses is the only medicine approved by the FDA for bulimia. It reduces binge and purge frequency and helps depression and anxiety.
• Bupropion should be avoided because it raises seizure risk in people with bulimia.

Medical and dental care

• regular electrolyte monitoring and replacement when needed
• gradual, supervised reduction of laxatives
• dental care: rinse with water or a fluoride mouthwash after vomiting rather than brushing immediately, which can strip softened enamel
• treatment of reflux and other complications
• hospital admission for dangerous electrolyte levels, severe dehydration, suicide risk, or failure of outpatient treatment

Recovery

Many people recover fully, especially with early treatment. Relapses can happen, particularly during stress, so learning to recognize early signs is part of treatment. Regular meals, avoiding strict diets, and support from family and friends help long-term recovery.

How to help someone with bulimia

• Choose a private, calm moment and express concern about specific behaviors without blame.
• Avoid comments about weight, appearance or food.
• Encourage seeing a doctor or therapist, and offer to help find one.
• Be patient: denial and shame are common.

Frequently asked questions

What are the signs of bulimia?

Signs include going to the bathroom after meals, hidden food or wrappers, laxative packets, swollen cheeks, calluses on the knuckles, tooth erosion, weight fluctuations, strict dieting between binges, excessive exercise and intense preoccupation with weight and shape.

What does bulimia do to your body?

Repeated purging can cause dangerously low potassium and heart rhythm problems, dehydration, kidney problems, damage to the esophagus, tooth erosion, swollen salivary glands, constipation, irregular periods and fatigue. Depression and anxiety are also common.

Can bulimia be cured?

Yes. Many people recover fully with treatment, especially cognitive behavioral therapy for eating disorders. Recovery takes time and relapses can occur, but long-term recovery is common, particularly when treatment starts early.

What is the difference between bulimia and binge eating disorder?

Both involve binge eating with loss of control. In bulimia, binges are followed by compensatory behaviors such as vomiting, laxatives, fasting or over-exercising. In binge eating disorder, there is no regular compensation.

Can you have bulimia at a normal weight?

Yes. Most people with bulimia are within or above the normal weight range. That is one reason bulimia can go unnoticed for years. Weight does not reflect how serious the illness is.