What Is Bulimia?
Bulimia, also known as bulimia nervosa, is an eating disorder characterized by binge eating following by compensatory purging or other methods to avoid weight gain or to relieve the physical symptoms that a person feels after binging. Purging usually involves vomiting, but it may also include the use of laxatives, excessive exercise, or fasting.
Like other eating disorders , people who have bulimia are often secretive about the condition due to feelings of shame or guilt about their behaviors. They may go to great lengths to hide their symptoms, which may result in family and friends missing the signs that there is a problem.
The signs and symptoms of bulimia can be physical, behavioral, and emotional.
Dentists are often the first to notice signs of self-induced vomiting in patients with bulimia nervosa because of the tell-tale pattern of dental erosion primarily on the internal surface of the teeth. But oral health concerns aren't the only physical symptom linked to bulimia. People may also experience:
- Bloodshot eyes
- Calluses on the back of the hand
- Chest pains
- Chronic bouts of constipation (resulting from laxative abuse)
- Electrolyte imbalances and dehydration
- Frequent sore throat
- Heart palpitations
- Lightheadedness or loss of balance (may experience fainting)
- Mouth ulcers
- Stomach aches
- Swelling of hands and feet
- Swollen glands and roundness in the jaw area
- Tooth cavities
- Tooth sensitivity
- Vomiting blood
- Yellowing, graying, spotted, or decaying teeth
Puffy cheeks among people whose purging include vomiting are one of the other noticeable physical signs. Calluses on the hand from inserting it in the mouth to cause vomiting may also be visible and are known as Russell's sign. Later in the illness, this sign may not even be visible as the person may be able to vomit without mechanical stimulation.
The following behavioral symptoms are those that are most often noticed outwardly by family members and friends.
- Creation of schedules or rituals that allow for binging and purging
- Desperation to exercise even when it gets in the way of other activities
- Evidence of binge eating including stashing food, stealing food, and eating large amounts in one sitting
- Evidence of purging such as always needing to go to the restroom or showering after meals or packages of laxatives or diuretics
- Exercising a specific amount to "burn off" the calories that have been taken in
- Extreme eating habits (strict dieting followed by overeating)
- Fatigued appearance
- Frequent trips to the bathroom
- Large amounts of food that are missing from the cabinets or pantry; large amounts of food packaging in trashcans or vehicles
- Talks about dieting, calories, food or weight so much that it gets in the way of regular conversation
- Uses drugs or detox teas as a way to suppress appetite
- Withdrawal from friends, families, and usual activities
Although more difficult to notice than behavioral symptoms, emotional symptoms are also often recognized by family members and friends, even when they don’t know about the binging and purging behaviors. These emotional issues are not unique to bulimia nervosa but may raise concerns.
- Extreme irritability
- Extremely self-critical
- Feeling out of control
- Mood swings
- Self-esteem, self-worth, or attractiveness determined by appearance and weight
- Strong need for approval
Most of the symptoms and signs associated with bulimia nervosa are reversible with treatment. If you don't have a doctor who specializes in mental health, feel free to start with speaking with your primary care physician.
A doctor or mental health professional will ask questions about physical health, mental health, behaviors, and medical history. A physical examination will also be performed and lab tests may be ordered to help rule out other conditions or diseases. Diagnosis can be complicated by the fact that many people with eating disorders hide their behaviors.
Bulimia nervosa is characterized by:
- Repeated episodes of binge eating, which is eating a large amount of food in a short period of time and feeling out of control while doing so
- The use of compensatory behaviors such as vomiting, fasting, using laxatives or diuretics, or engaging in extreme amounts of exercise in order to offset eating.
- Self-evaluation is unjustifiably influenced by body shape and weight.
Because many people who have bulimia are of average weight, physical symptoms of bulimia may not be noticeable to others until the disorder has become extremely severe. It is important for anyone experiencing associated symptoms to be assessed by a physician.
In addition to these diagnostic criteria, the binging/purging must occur at least once a week for the last three months. and the behavior must not be caused by anorexia.
If you or someone you know is showing signs of bulimia nervosa, please seek out or encourage your loved one to seek out professional help. Simply having a conversation about your behaviors toward food, eating, stress, and more can give your doctor valuable insight to help you.
Bulimia vs. Other Eating Disorders
Sometimes, people with anorexia nervosa will also use binging or purging behaviors. However, the distinction between bulimia nervosa and anorexia nervosa is that people struggling with anorexia nervosa have significantly low body weight. Additionally, people who binge but do not purge may meet the criteria for binge eating disorder.
Bulimia Discussion Guide
Get our printable guide for your next doctor's appointment to help you ask the right questions.
The exact causes of bulimia are not known, but there are a number of factors that may play a role:
- Biological factors
- Distorted body image
- Having family members with eating disorders
- Media influences and exposure to unhealthy role models
- Negative thought patterns
- Learned behaviors
It is also not uncommon for people with bulimia to have co-occurring mental health conditions including depression, anxiety, obsessive-compulsive disorder (OCD), and substance use disorders.
Treatment for bulimia focuses on changing binging-purging behaviors and replacing distorted thought patterns. A treatment plan will often involve psychotherapy, medications, and nutritional education. Because treatment addresses many different life areas, it often involves a treatment team that may include doctors, mental health professionals, and dietitians.
Three forms of psychotherapy that are often helpful in the treatment of bulimia include:
- Cognitive behavioral therapy (CBT) : This type of therapy focuses on identifying and changing the negative underlying thoughts and attitudes about weight and shape. People learn to change these thoughts and adopt healthier behaviors. People also develop coping mechanisms and learn how to delay purging behaviors .
- Dialectical-behavior therapy (DBT) : This approach incorporates CBT and focuses on improving relationships, practicing mindfulness , increasing distress tolerance, and learning emotional management skills.
- Family-based treatment (FBT) : This approach is family-focused and initially involves parents or caregivers taking complete control of the individual's eating. Eventually, the individual is able to gradually regain control of meal planning and eating until they achieve healthy independence.
Treatment for bulimia may also include the use of antidepressant medications including:
- Selective serotonin reuptake inhibitors (SSRIs) such as Zoloft (sertraline), Prozac (fluoxetine), and Paxil (paroxetine)
- Selective norepinephrine reuptake inhibitors (SNRIs) such as Effexor (venlafaxine) and Cymbalta (duloxetine)
Getting appropriate treatment is essential, but there are also things you can do to take care of yourself during your recovery.
- Treat yourself kindly. Avoid criticizing yourself or expecting immediate results. It takes time to establish new ways of thinking and healthy habits.
- Stick to your plan. Even when you are tempted to stray from your therapy or eating plan, focus on sticking with it. It's normal to feel uncomfortable at times, so be sure to talk to your doctor or therapist about the difficulties you are dealing with.
- Use relaxation techniques. Find ways to cope with feelings of distress such as visualization, deep breathing , or progressive muscle relaxation .
- Rely on your support system. Talk to the people you are closest to and discuss the kind of support you need. Reach out to these people during times when you need extra help or a safe space.
- Use positive self-talk. In addition to addressing negative thoughts and self-perceptions in therapy, work on using positive self-talk in your daily life. If you find yourself dwelling on negative thoughts, look for ways to reframe those thoughts in a more realistic, positive way.
If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237 .
For more mental health resources, see our National Helpline Database .
Mehler PS, Rylander M. Bulimia Nervosa - medical complications . J Eat Disord . 2015;3:12. doi:10.1186/s40337-015-0044-4
National Eating Disorders Association. Bulimia Nervosa .
Levinson CA, Zerwas S, Calebs B, et al. The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis . J Abnorm Psychol. 2017;126(3):340-354. doi:10.1037/abn0000254
American Psychiatric Association. What Are Eating Disorders? .
Cleveland Clinic. Bulimia nervosa: diagnosis and tests .
NEDA. Bulimia nervosa .
Cleveland Clinic. Bulimia nervosa: management and treatment .
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author; 2013.
Mehler S, Andersen A. Eating Disorders: A Guide to Medical Care and Complications . Baltimore: The John Hopkins University Press; 2010.