Bulimia

Bulimia nervosa is an eating disorder and mental health condition. People with bulimia are very anxious about their weight and focused on having the ‘right’ body shape. They also spend a lot of time thinking about food.

People with bulimia overeat in a pattern known as ‘binge eating’, meaning they eat a lot of food (or what feels to them like a lot of food) in a short space of time. They then try to avoid digesting the food and gaining weight from it by ‘purging’. There are a number of ways people purge, including making themselves vomit or using laxatives (medication that causes you to poo).

Read more about bulimia symptoms

How common is bulimia?

It’s estimated that bulimia affects around 1.5% of women and 0.5% of men across the course of a lifetime. It’s unusual for bulimia symptoms to develop before puberty, and the most common time for the condition to develop is the teenage years.

Treating bulimia

Bulimia can be treated using a number of different talking therapies, including guided self-help and cognitive behavioural therapy for eating disorders (CBT-ED).

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem. Then, you need to visit your GP for a medical check-up and advice on how to get treatment.

If you think someone you know has bulimia nervosa, talk to them and try to persuade them to see their GP.

Read more about treating bulimia

The main symptoms of bulimia are:

• bingeing – overeating in a particular pattern
• purging – trying to reduce the effect of binging by attempting to get calories out of your body
• focus on food – thinking about food all the time, even when you don’t want to
• problems with self-esteem and focus on body image when it comes to food and weight

Binge eating

In order for an episode of binge eating to be considered a binge, it should have 2 key features. The first is that the amount of food eaten is far more than normal for the situation – for example, many people eat a lot more on Christmas Day than they would on any other day, but this is normal for the situation, so it wouldn’t qualify as a binge.

The second feature is a feeling that the eating is out of control – feeling as if you can’t stop eating. You might feel disconnected – as if you’re watching the binge happen from outside your body.

There may be times when a person eats a relatively small amount of food, but it still feels like a binge because they feel a loss of control.

Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.

Binge eating episodes are sometimes spontaneous, where you eat anything you can find. They can also be planned, where you make a shopping trip to buy foods specifically to binge on.

People often find eating comforting. Binges can start as a way to cope with difficult emotions, but become increasingly frequent and out of control.

Purging

After bingeing, you might feel guilty, anxious, and angry with yourself. You may also feel uncomfortable physically, for example you might feel sick or bloated from the amount you’ve eaten. Purging is a response to these feelings, as well as an attempt to ‘undo’ any weight gain that could be caused by the binge.

There are a number of ways that people try to purge:

• making yourself vomit
• taking laxatives (medicine that makes you poo)
• taking illegal drugs, such as amphetamines, to try to make your body burn energy faster

In reality, purging has little effect on the calories absorbed from food.

Focus on food

People with bulimia experience ‘intrusive thoughts’ about food. Intrusive thoughts are unwanted thoughts that come into your mind without you wanting to think about them. Because people with bulimia are concerned about gaining weight and body image, but they also consider food something comforting, these thoughts cause distress.

Part of the problem for many people with bulimia is that they’ve learned that eating is comforting. When they feel distress, they want to eat in order to feel better.

People with bulimia also often restrict what they eat, which means that they are feeling hungry often, so they think more about food. When someone is very hungry, intrusive thoughts about food are likely.

After a certain period of time where people with bulimia try to avoid eating, in order to avoid gaining weight, they are likely to lose control and binge.

Problems with self-esteem and focus on body image

People with bulimia often have problems with their self-esteem in general, and as a result can spend a lot of time thinking about their body shape and eating habits. This can lead to setting strict rules about dieting, eating or exercising, which are very hard to maintain.

When people with bulimia are unable to keep to these strict rules, they tend to binge eat. After feeling guilty about binging, they purge to get rid of the calories.

These feelings of guilt then further affect self-esteem, causing what’s often called a ‘cycle of guilt’.

The exact causes of bulimia are unclear, but most specialists believe it's likely to be the result of a combination of factors.

Psychological factors

Many people who develop bulimia share certain patterns of thinking and behaving that may make them more likely to develop the condition. These include:

• a tendency towards depression and anxiety
• finding it difficult to handle stress
• frequently worrying and feeling scared or doubtful about the future
• perfectionism – setting strict, demanding goals or standards that are unrealistic for them to maintain
• finding it hard to express feelings
• experiencing unwanted thoughts, images or urges that make them feel they have to behave in certain ways

Environmental factors

Environmental factors are parts of the world around a person, and events happening in their life, that can affect their mental wellbeing in a variety of ways.

Puberty can be an important factor contributing to bulimia. This is likely due to the combination of hormonal changes and feelings of stress, anxiety and low self-esteem during puberty.

Stressful life changes – for example, moving house, the breakdown of a relationship, going to college or university, or a bereavement – can also have an impact. When these changes happen during puberty, the effect can be even greater.

Western culture and society may also play a part. People of all ages are exposed to a wide range of media messages promoting the idea that only certain body shapes are desirable, and that not having the ‘ideal’ body is something to be ashamed of. Even health advice that’s intended to be helpful can have a focus on the risks of being overweight, which can add to feelings of pressure and low self-esteem.

The media also places significant focus on celebrities’ bodies, pointing out things like cellulite or slight weight gain. This can make people feel insecure about these parts of their own bodies.

Other environmental factors that can contribute towards bulimia include:

• pressure and stress at school, such as exams or bullying – particularly if someone is bullied about body weight or shape
• occupations or hobbies where being thin is seen as the ideal, such as dancing or athletics
• having a family that places high value on being thin and physically active, and praises or rewards weight loss
• difficult family relationships
• physical or sexual abuse

Biological and genetic factors

The risk of developing bulimia is thought to be greater in people with a family history of eating disorders. This suggests that genetics could contribute to developing bulimia.

As with other mental health conditions, like depression, people with bulimia might have some differences in the way their brains work compared to people who don’t have the condition. These differences may affect the part of the brain that’s linked to appetite and body image.

When making a diagnosis, your GP will probably ask questions about your eating habits. For example, they could ask:

• how you feel about your weight, and if you’re concerned about it
• if you make yourself vomit regularly
• if you binge-eat

It’s important to answer these questions honestly. Your GP isn’t trying to judge you or ‘catch you out’. They just need to accurately assess how serious your symptoms are.

Weight and BMI

Your GP may check your weight and calculate your body mass index (BMI). A healthy BMI for adults in Scotland is 20-25.

Find out how to calculate your BMI

Blood tests and other tests

Your GP may not need to carry out any tests to diagnose bulimia, but they’ll probably check your pulse and blood pressure.

Sometimes an ECG (electrocardiogram) may be needed to check how well your heart is working.

Your GP may do blood tests to check the level of:

• fluids in your body
• chemicals or minerals, such as potassium in your blood

Blood tests look for the complications of bulimia, so even if they come back as ‘normal’, you may still benefit from a referral to a specialist if you’re experiencing bulimia symptoms.

Referral to a specialist

If your GP thinks you may have bulimia, they’ll refer you to a specialist in eating disorders for a more detailed assessment – see Treating bulimia for more information.

Before your treatment begins, you will probably have an overall assessment of your health. This may be done by your GP or another healthcare professional, such as one that specialises in eating disorders.

The assessment will help your healthcare professional draw up a plan for your treatment and care. For example, they may assess:

• your overall health and any medical needs
• your social situation, such as how much support you have from family and friends
• your mood and any risks that affect you, such as whether you are at risk of harming yourself
• whether there are any physical risks as a result of bulimia that mean urgent treatment is needed

Your care plan

For many people, guided self-help can be an effective treatment for bulimia. Guided self-help is where you work through information and activities on your own, and have regular support sessions with a professional (usually a psychologist). These activities can include filling out worksheets, keeping a food diary and meal plan, and writing about difficult thoughts and feelings.

If this is unsuccessful, your GP can refer you for treatment to an eating disorder service, where you may be offered a structured programme of psychological treatment.

Some people may also benefit from antidepressant medication (fluoxetine), as this can reduce the urges to binge and vomit.

Psychological treatment

The main type of psychological treatment for bulimia is cognitive behavioural therapy (CBT). CBT starts with the idea that thoughts, feelings, and behaviour are linked and affect one another. If bulimia is causing someone to behave in an unhealthy way, CBT helps them to change the harmful behaviour while working on changing how they think about food, eating, and weight.

One alternative to CBT is interpersonal therapy (IPT). IPT is based on the idea that relationships with other people and the outside world in general have a range of effects on your mental health, both positive and negative. IPT explores the way you interact with other people and the relationships you have, with the goal of improving them.

Learn more about talking therapies

The types of therapy available can vary depending on where you live. Although different types of therapy take different approaches, the most important part of any talking therapy is the relationship you build with your therapist.

Medication

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may be used to treat bulimia. The SSRI usually recommended to treat bulimia is called fluoxetine (brand name Prozac).

As with any antidepressant, an SSRI will usually take several weeks before it starts to work. You’ll usually be started on a low dose, which is then gradually increased as your body adjusts to the medicine.

When you start taking an SSRI, see your GP after 2, 4, 6 and 12 weeks to check your progress and to see if you’re responding to the medicine. Not everyone responds well to antidepressant medicines, so it's important your progress is carefully monitored.

Very few drugs are recommended for children and young people below the age of 18. It’s also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.

Relapse

Recovery from bulimia can take a long time, and it’s quite common for bulimia symptoms to return after treatment – this is often referred to as relapse, and is more likely during times of stress. If relapse happens, the approach to getting treatment is the same – the first step is going to your GP.

There are a number of physical complications associated with bulimia.

These can include:

• dental problems – regular vomiting can cause your stomach acid to damage the enamel on your teeth, which can lead to tooth decay
• repeated vomiting can cause bad breath and a sore throat
• due to a lack of nutrients, your skin and hair can become dry and your fingernails can become brittle
• your saliva glands can become swollen from frequent vomiting, which makes your face appear rounder
• frequent vomiting or laxative use can cause chemical imbalances in your body – this can cause tiredness, weakness, abnormal heart rhythms, kidney damage, convulsions (fits), and muscle spasms
• frequent use of laxatives can damage your bowel muscles, resulting in permanent constipation (finding it difficult to poo)
• long-term complications of bulimia can include an increased risk of heart problems

If you have periods, bulimia can cause them to become unpredictable, or even stop altogether. This does not mean bulimia makes you infertile – while it may be harder to get pregnant, you should continue to use birth control if you aren’t planning a pregnancy.

If you have diabetes, you’ll need regular health checks to help avoid problems with your eyes or other serious complications. This is particularly important if you have type 1 diabetes.

Hospital treatment

Bulimia isn’t usually treated in hospital. However, if you have serious health complications and your life is at risk, you may be admitted to hospital.

If someone has bulimia, the most important steps towards diagnosis and treatment are for them to:

• recognise they need help
• want to get better

However, to take this first step they may need lots of support and encouragement. It’s understandable that people who have bulimia can be anxious about seeking treatment that might mean making changes to their eating habits.

Helping yourself

If you have eating problems or think you may have bulimia, it’s important to seek help as soon as possible. You could start by:

• talking to someone you trust, such as a friend or member of your family
• going to see your GP – you may find it helpful to bring someone with you for support

Helping someone else

If someone close to you is showing signs of bulimia, you can offer help and support.

You could try talking to them about how they feel, and encourage them to think about getting help. Try not to put pressure on them or be critical of them, as this could make things worse. You could also offer to help by going with the person to see their GP.

If you’d like to get some advice on how to help, a healthcare professional, such as your own GP, can provide information on:

• how to help the person recognise that they have a problem
• the treatments available
• how you can support them during their treatment

You could also get help from a support group for people who have loved ones with eating disorders. Your own GP or Scotland’s Service Directory can help you find services near you.

A leading charity for people with eating disorders is Beat, which has a range of information on the help and support available for people with eating disorders, and their friends and families.