What is bulimia?

Bulimia (also called bulimia nervosa) is a condition where you think a lot about your body weight and shape. It affects your ability to have a 'normal' eating pattern. Bulimia nervosa is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia, you are most likely to be normal weight or even overweight.

How do you know if you have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder:

• Do you believe you're fat when others think you're thin?
• Do you make yourself sick because you are uncomfortably full?
• Do you worry that you've lost control over how much you eat?
• Have you lost more than 13 pounds in the past three months?
• Would you say that food dominates your life?

Who gets bulimia?

Bulimia nervosa mainly affects women aged 16-40. It most commonly starts around the age of 19 years. It affects around 8 in 100 women in the UK. Bulimia nervosa sometimes develops in men and children. Women are 10 times more likely to develop bulimia nervosa than men. However, bulimia nervosa is becoming more common in boys and men. Bulimia nervosa is more common than anorexia nervosa.

There may be some genetic factor, as the risk of developing bulimia nervosa in close relatives of individuals with bulimia nervosa is four times greater than in the general population.

What are the symptoms of bulimia?

Bingeing and purging are the main symptoms and are usually done in secret.

• Bingeing means that you have repeated episodes of eating large amounts of foods and/or drinks. For example, you may eat a whole large tub of ice cream or two packets of biscuits even if you are not hungry. You feel out of control and unable to stop eating. Binge eating is often done very quickly until you feel physically uncomfortable. This happens not just on one occasion, but regularly. Eating patterns typically become chaotic.

• Purging means that you try and counteract the 'fattening' effects of the food from the bingeing. Self-induced vomiting (making yourself sick) after a bout of bingeing is the most well-known, but not all individuals with bulimia nervosa do this. Other purging methods include taking lots of laxatives, extreme exercise, extreme dieting or even periods of complete starvation, taking diuretics (water tablets) or taking other medicines such as amphetamines.

The reasons why you binge eat and then purge may not be easy to explain. Part of the problem may be due to a fear of getting fat, although it is often not just as simple as that. All sorts of emotions, feelings and attitudes may contribute. The physical act of bingeing and purging may be a way of dealing with your emotions in some way.

What are the physical problems caused by bulimia nervosa?

These are caused by the unusual eating habits and the methods used to purge the body of food (such as vomiting or the excessive use of laxatives). Physical problems do not always develop. They are more likely if you binge and purge often. One or more of the following may develop:

1. Bowel problems— These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.
2. Chemical imbalances in the body— These are caused by either repeated vomiting or excess use of laxatives. For example, low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to tetany (muscle spasms).
3. Depression— It is fairly common to feel low when you have bulimia nervosa. Some individuals even become depressed, which can respond well to recovery. It is important to talk about any symptoms of depression you may have. Many individuals find they become more moody or irritable.
4. Irregular periods— Many individuals have irregular periods as hormone levels can be affected by poor diet. Periods may even stop all together or you may find that your periods have never started, especially if you started having eating problems when you were younger.
5. Psychological problems— These are very common and include feelings of guilt and disgust after bingeing and purging. Poor self-esteem and mood swings are common.
6. Swelling of hands, feet and face— This is usually due to fluid disturbances in the body. The saliva glands in the face can sometimes swell due to the frequent vomiting.
7. Teeth problems— These can be caused by the acid from the stomach rotting away the enamel as a result of repeated vomiting.

What causes bulimia?

The exact cause is not clear. Some individuals blame the media and the fashion industry which portray the idea that it is fashionable to be slim. This can put pressure on some individuals to try to be slim which can then lead to an eating disorder.

There may be some genetic factor to developing bulimia nervosa, which is triggered by stressful or traumatic life experiences. For example, some individuals with bulimia nervosa have had a childhood where there were frequent family problems with arguments and criticism at home. Some individuals with bulimia nervosa have been abused as a child.

Sometimes bulimia nervosa is also associated with some other psychological problem. (That is, the bulimia nervosa is sometimes just a part of a broader mental health problem.) For example, there is a higher than average rate of bulimia nervosa in individuals with anxiety disorders, obsessive compulsive disorder, depression, post-traumatic stress disorder and some personality disorders.

A chemical called serotonin which is in parts of the brain is thought to have something to do with bulimia nervosa. In some way one or more of the above factors, or even other unknown factors, may lead to a low level of serotonin.

Are there any tests done for bulimia nervosa?

Although there is not an actual test to diagnose bulimia nervosa, your doctor may wish to undertake some blood tests. These are usually done to check your kidney function and potassium levels.

What are the recovery techniques for bulimia?

The aim of recovery is to:

• Encourage healthy eating.
• Help individuals become both physically and mentally stronger.
• Reduce other related symptoms and problems.
• Reduce risk of harm which can be caused by bulimia nervosa.

Many individuals with bulimia nervosa who see their GP will be referred to a specialist mental health team. Members of the team may include psychiatrists, psychologists, nurses, dietitians and other professionals. If you have more severe bulimia nervosa you may be referred to a specialist eating disorder unit.

The sorts of recovery techniques that may be offered include the following:

1. Psychological ('talking') recovery techniques— Cognitive behavioral therapy (CBT) is the most commonly used psychological treatment for bulimia nervosa. It helps you to look at the reasons why you developed bulimia nervosa, aims to change any false beliefs that you have about your weight and body, and it helps to show you how to deal with emotional issues. Talking recovery techniques take time and usually require regular sessions over several months. Recovery may also involve other members of your family going to meetings to discuss any family issues. However, CBT does not suit everyone. About a third of individuals drop out before finishing the course. Other forms of psychological recovery techniques may also be used. For example, cognitive analytic therapy (CAT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy.

2. Medication— A medicine may be advised by your doctor. The most commonly used medicines are selective serotonin reuptake inhibitor (SSRI) antidepressants. These are used to treat depression but, in higher doses, one called fluoxetine can reduce the urge for bingeing or purging. These are not usually recommended if you are younger than 18 years old. Treatment of any physical or teeth problems that may occur. This may include taking potassium supplements, dental care and not using laxatives.

3. Help with eating— It is best if you have regular meals; even if you only eat small meals. It is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other individuals) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary in order to write down all the food that you eat.

Self-help measures—

Self-help methods for the recovery of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Self-help support groups are an especially powerful and effective means of ensuring long-term treatment compliance and decrease the relapse rate. Individuals find they can bounce ideas off of one another, get objective feedback about body image, and just gain increased social support. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

There are a number of self-help books and manuals available. These provide strategies in how to cope with, and overcome, bulimia nervosa. Some individuals find these very helpful and prefer them to 'formal' treatment. It is certainly worth trying a self-help manual if there is a waiting list or difficulty in getting psychological treatment.

Anorexia and bulimia aren’t about food. They’re about using food to cope with painful emotions such as anger, self-loathing, vulnerability, and fear. Disordered eating is a coping mechanism–whether you refuse food to feel in control, binge for comfort, or purge to punish yourself. But you can learn healthier ways to cope with negative emotions.

The first step is figuring out what’s really eating you up inside. Remember, “fat” is not a feeling, so if you feel overweight and unattractive, stop and ask yourself what’s really going on. Are you upset about something? Depressed? Stressed out? Lonely? Once you identify the emotion you’re experiencing, you can choose a positive alternative to starving or stuffing yourself.

Here are a few suggestions to get you started:

• Call a friend
• Listen to music
• Play with a pet
• Read a good book
• Take a walk
• Write in a journal
• Go to the movies
• Get out into nature
• Play a favorite game
• Do something nice for someone else

Emotional Do and Don't Lists—


• use individuals to comfort you when you feel bad, instead of focusing on food
• let your emotions come and go as they please without fear
• fully experience every emotion
• be open and accepting of all your emotions
• allow yourself to be vulnerable with individuals you trust


• avoid feelings because they make you uncomfortable
• focus on food when you’re experiencing a painful emotion
• let individuals shame or humiliate you for having or expressing feelings
• pretend you don’t feel anything when you do
• worry about your feelings making you fall apart

Improving your self-image—

You are more than what you weigh, a fact you lose sight of when you have an eating disorder. When you base your self-worth on physical appearance alone, you’re ignoring all the other qualities, accomplishments, and abilities that make you beautiful. Think about your friends and family members. Do they love you for the way you look or who you are? Chances are, your appearance ranks low on the list of what they love about you–and you probably feel the same about them. So why does it top your own list?

Placing too much importance on how you look leads to low self-esteem and insecurity. But you can learn to see yourself in a positive, balanced way:

• Challenge negative self-talk. When you catch yourself being self-critical or pessimistic, stop and challenge the negative thought. Ask yourself what evidence you have to support the idea. What is the evidence against it? Just because you believe something, doesn’t mean it’s true. Answering these questions will help you see things in a more realistic light.

• Focus on what you like about your body. Instead of searching for flaws when you look in the mirror, appreciate the things you like about your appearance. If you’re distracted by “imperfections,” remind yourself that nobody’s perfect. Even supermodels get airbrushed.

• Make a list of your positive qualities. Think of all the things you like about yourself. Are you smart? Kind? Creative? Loyal? Funny? What would others say are your good qualities? Include your talents, skills, and achievements. Also think about bad qualities you don’t have.

Learning healthy eating habits—

If you’ve been struggling with an eating disorder, chances are you’ve forgotten what healthy eating looks like. But learning and establishing healthy eating habits is an essential step in recovery from anorexia and bulimia.

• Challenge your strict eating rules. Strict rules about food and eating fuel anorexia and bulimia, so it’s important to replace them with healthier ones. For example, if you have a rule forbidding all desserts, change it into a less rigid guideline such as, “I won’t eat dessert every day.” You won’t gain weight by enjoying an occasional ice cream or cookie.

• Don’t diet. Healthy eating–not dieting–is the key to avoiding weight gain. Instead of focusing on what you shouldn’t eat, focus on nutritious foods that will energize you and make your body strong. Think of food as fuel for your body. Your body knows when the tank is low, so listen to it. Eat when you’re truly hungry, then stop when you’re full. If you follow these simple guidelines -- your body will look and feel its best.

• Stick to a regular eating schedule. You may be used to skipping meals or fasting for long stretches. But when you starve yourself, food becomes all you think about. To avoid this preoccupation, make sure to eat every three hours. Plan ahead for meals and snacks, and don’t skip!

Find a specialist—

The first step in eating disorder recovery is finding a doctor or therapist who specializes in anorexia and bulimia. As you search, focus on finding the right fit. Your relationship with your doctor or therapist is important to the recovery process. Look for someone who makes you feel comfortable, accepted, and safe.

To find an eating disorder recovery specialist in your area:

• Ask your primary care doctor for a referral
• Ask your school counselor or nurse
• Call the National Eating Disorders Association’s toll-free hotline at 1-800-931-2237 (Mon–Fri, 8:30 a.m. to 4:30 p.m. PST)
• Check with local hospitals or medical centers
• Search online at the eating disorder websites listed to the right

Address health problems—

Anorexia and bulimia can be deadly–and not just if you’re drastically underweight. Your health may be in danger, even if you only occasionally fast, binge, or purge, so it’s important to get a full medical evaluation. If the evaluation reveals health problems, they should take top recovery priority. Nothing is more important than your physical well-being. If you’re suffering from any other life-threatening problem, you may need to be hospitalized. While the thought of hospitalization may be scary, try to remember that its sole purpose is to keep you safe!

Make a long-term recovery plan—

Once your health problems are under control, you and your doctor or therapist can work on a long-term recovery plan. First, you’ll need to assemble a complete eating disorder recovery team. Your team might include a family doctor, a psychologist, a nutritionist, a social worker, and a psychiatrist. Then you and your team will develop a recovery plan that’s individualized to meet your needs.

Relapse prevention—

The work of eating disorder recovery doesn’t end once you’ve adopted healthy habits. It’s important to take steps to maintain your progress and prevent relapse.

• Avoid pro-ana and pro-mia websites. Don’t visit websites that promote or glorify anorexia and bulimia. These sites are run by individuals who want excuses to continue down their destructive path. The “support” they offer is dangerous and will only get in the way of your recovery.
• Develop a solid support system. Surround yourself with individuals who support you and want to see you healthy and happy. Avoid individuals that drain your energy, encourage your disordered eating behaviors, or make you feel bad about yourself.
• Fill your life with positive activities. Make time for activities that bring you joy and fulfillment. Try something you’ve always wanted to do, develop a new skill, pick up a fun hobby, or volunteer in your community. The more rewarding your life, the less desire you’ll have to focus on food and weight.
• Identify your “triggers”. Are you more likely to revert to your old, destructive behaviors during the holidays, exam week, or swimsuit season? Know what your triggers are, and have a plan for dealing with them, such as going to therapy more often or asking for extra support from family and friends.
• Keep a journal. Writing in a daily journal can help you keep tabs on your thoughts, emotions, and behaviors. If you notice that you’re slipping back into negative patterns, take action immediately.
• Stick with your eating disorder recovery plan. Don’t neglect therapy or other components of your recovery, even if you’re doing better. Listen to the advice of your recovery team and continue to follow their recommendations.

What is the prognosis?

Bulimia nervosa is the sort of condition that is difficult to cure fully 'once and for all'. Many individuals improve with treatment, but bad spells (relapses) may recur from time-to-time in some cases. Many individuals find they still have issues with food, even after recovery, but they are more in control and can lead happier, more fulfilled lives.

Studies suggest that 10 years after a diagnosis of bulimia nervosa about 5 in 10 individuals are well, about 2 in 10 individuals still have bulimia nervosa, and about 3 in 10 individuals are somewhere in the middle. However, the recent study about CBT treatment (cited at the end) suggests that with good quality CBT, the outlook is probably even better than these 'overall' figures. It is very unusual to die from bulimia nervosa.

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