What is Bulimia Nervosa?

Updated: Oct 6, 2020

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Bulimia nervosa (BN) is binge eating, followed by purging. Purging is anything that overcompensates for consuming large amounts of food and can include excessive exercise, vomiting, fasting, unnecessary use of laxatives and diuretics, or enemas.

Diagnosis Criteria

Credit to NEDA.

  • Recurring episodes of binge eating, characterized by the following:

  • Eating an excessive amount of food for body size in a small amount of time

  • Feeling a lack of control while eating

  • Reactionary behavior to prevent weight gains such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

  • Episodes must occur once a week for three consecutive months

  • A negative perception of body and weight

  • Events don't necessarily need to occur with anorexia nervosa


Credit to NEDA.

Emotional and behavioral

  • In general, behaviors and attitudes indicate that weight loss, dieting, and control of food are becoming primary concerns

  • Evidence of binge eating, including the disappearance of large amounts of food in short periods or lots of empty wrappers and containers indicating consumption of large quantities of food

  • Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics

  • Appears uncomfortable eating around others

  • Develops food rituals (e.g., eats only a particular food or food group [e.g., condiments], excessive chewing, doesn't allow foods to touch)

  • Skips meals or takes small portions of food at regular meals

  • Disappears after eating, often to the bathroom

  • Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)

  • Fear of eating in public or with others

  • Steals or hoards food in strange places

  • Drinks excessive amounts of water or non-caloric beverages

  • Uses excessive amounts of mouthwash, mints, and gum

  • Hides body with baggy clothes

  • Maintains extreme, rigid exercise regimen – despite the weather, fatigue, illness, or injury—due to the need to "burn off" calories

  • Shows unusual swelling of the cheeks or jaw area

  • Has calluses on the back of the hands and knuckles from self- induced vomiting

  • Teeth are discolored, stained

  • Creates lifestyle schedules or rituals to make time for binge-and-purge sessions

  • Withdraws from usual friends and activities

  • Looks bloated from fluid retention

  • Frequently diets

  • Shows extreme concern with body weight and shape

  • Frequent checking in the mirror for perceived flaws in appearance

  • Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating

  • Purges after a binge (e.g. self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, fasting)

  • Extreme mood swings


  • Noticeable fluctuations in weight, both up and down

  • Bodyweight is typically within the healthy weight range; may be overweight

  • Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)

  • Difficulties concentrating

  • Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)

  • Dizziness

  • Fainting/syncope

  • Feeling cold all the time

  • Sleep problems

  • Cuts and calluses across the top of finger joints (a result of inducing vomiting)

  • Dental problems, such as enamel erosion, cavities, and tooth sensitivity

  • Dry skin

  • Dry and brittle nails

  • Swelling around area of salivary glands

  • Fine hair on body

  • Thinning of hair on head, dry and brittle hair (lanugo)

  • Cavities, or discoloration of teeth, from vomiting

  • Muscle weakness

  • Yellow skin (in context of eating large amounts of carrots)

  • Cold, mottled hands and feet or swelling of feet

  • Menstrual irregularities — missing periods or only having a period while on hormonal contraceptives (this is not considered a "true" period)

  • Poor wound healing

  • Impaired immune functioning

Many people with bulimia nervosa also struggle with co-occurring conditions, such as:

  • Self-injury (cutting and other forms of self-harm without suicidal intention)

  • Substance abuse

  • Impulsivity (risky sexual behaviors, shoplifting, etc.)

  • Diabulimia (intentional misuse of insulin for type 1 diabetes)


For the most part, the cause of BN is unknown. Research has shown that there isn't one cause connected to every case of bulimia, but a multitude of interchangeable reasons. Not every case is the same. Causes are physiological, biological, and environmental.

Studies have shown a link between bulimia and serotonin levels. Serotonin is a chemical in the brain that affects a variety of psychological and biological factors, including hunger, anxiety, impulsivity, perception, and memory.

Mental Health Disorders. Other mental health disorders can lead to BN. Studies show that half of binge eating disorder patients have a history of depression or other mental illness. Many people report negative emotions associated with bulimia such as anxiety, boredom, anger, and sadness.

Run in Families. Families share not only genetics but also eating habits. Though more research is required, some studies have indicated that eating disorders can be passed down from generation to generation through genetic factors. Parents also pass down their eating habits to their children, so if the parents have a pattern of bulimia, the children will more likely too.

Emotional Trauma. Stress can cause BN, more specifically, stressful life events like divorce, abuse, or death. Eating disorders can be used as a coping mechanism for traumatic experiences.

Weight Problems. One characteristic of bulimia nervosa patients is the fear of gaining weight. Either could come first, BN or weight issues, but there is no dispute that the problems are related.

Body Image. People with a negative body image are more likely to develop an eating disorder. In an obesity study, individuals who were overweight and individuals with binge eating disorder reported that self-esteem related to weight and shape. A negative body image can develop if a person is influenced by media or wants to live up to societal standards or norms. An adverse body image can lead to frequent dieting and overeating.


Credit to NEDA.

Bulimia is at a higher prevalence than previously thought. One study concluded that 1.0% of young women and 0.1% of young men met the diagnostic criteria at any given time. A 2007 survey of Americans found that 1.5% of women and 0.5% of men had bulimia during their lifetime. A review paper combined several studies to deduced that 1.1% and 4.6% of women and 0.1% to 0.5% of men would develop bulimia. Though the rate of bulimia nervosa patients hasn't been nailed down, research and clinical reports agree that eating disorder symptoms develop early in both males and females.

Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu.

Hoek HW and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4):383-96. doi: 10.1002/eat.10222.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040.

Micali N, Hagberg KW, Petersen I, and Treasure JL. (2013). The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open, 3(5): e002646. doi: 10.1136/bmjopen-2013-002646.

Smink FR, van Hoeken D, and Hoek HW. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4):406-14. doi: 10.1007/ s11920-012-0282-y.

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481.

van Son GE, van Hoeken D, Bartelds AI, van Furth EF, and Hoek HW. (2012). Time trends in the incidence of eating disorders: a primary care study in the Netherlands. International Journal of Eating Disorders, 39(7):565-9. doi: 10.1002/eat.20316.

Health Consequences

Cardiovascular System

  • When you don't consume enough calories, the body breaks down its tissue for fuel instead. The first tissue to be used is a muscle, including the heart. The more mass the heart loses, the more pulse and blood pressure drop. The heart has less fuel and cells to pump blood, and the risk of heart failure increases.

  • The body will reduce its resting metabolic rate to conserve energy.

  • If the brain and blood vessels can't push enough blood to the brain, it can cause fainting or dizziness, primarily upon standing.

  • Vomiting or laxatives can deplete body electrolytes. Electrolytes are used to help the heartbeat and other neurological activities. Imbalances in these chemicals can lead to irregular heartbeats, heart failure, and possibly death.

Gastrointestinal System

  • Eating disorders can lead to slow digestion, known as gastroparesis. Food restriction interferes with regular stomach emptying and the digestion of nutrients, which can lead to:

  1. Stomach pain and bloating

  2. Nausea and vomiting

  3. Blood sugar fluctuations

  4. Blocked intestines from solid masses of undigested food

  5. Bacterial infections

  6. Feeling full after eating only small amounts of food

  • A BN patient can develop constipation, from any of the following:

  1. Inadequate nutritional intake means the intestines don't have enough material for work properly.

  2. Long-term inadequate nutrition can weaken the muscles of the intestines and leave them without the strength to propel digested food out of the body

  • Both malnutrition and purging can cause pancreatitis, an inflammation of the pancreas. Symptoms include pain, nausea, and vomiting.

  • If a BN patient overeats food in a short window of time, the stomach can rupture, which is life-threatening.

  • Frequent vomiting can degrade the esophagus and lead to bursting, which is fatal. It can also cause sore throats and a hoarse voice.

  • Persistent vomiting can lead to swelling of the salivary glands.


  • The brain consumes almost one-fifth of the body's daily calorie intake. Inadequate nutritional intake causes low energy availability for the brain.

  • Extreme hunger at bedtime can create difficulties falling or staying asleep.

  • Neurons in all parts of the body require a protective layer of lipids for insulation; these lipids allow neurons to conduct electricity more efficiently. If the body doesn't have enough fat, it can damage this protective layer and cause numbness and tingling.

  • Severe dehydration and malnutrition can lead to electrolyte imbalances. Electrolytes are used by neurons to send electrical and chemical signals in the body. These imbalances can lead to seizures and muscle cramps.


  • Hormones are made from the fat and cholesterol we eat. Without the correct nutrients, levels of the following hormones can fall:

  1. Sex hormones estrogen and testosterone

  2. Thyroid hormones

  • Lowered sex hormones can

  1. cause menstruation to fail to begin, to become irregular, or to stop completely.

  2. significantly increase bone loss (known as osteopenia and osteoporosis) and the risk of broken bones and fractures.

  • Reduced resting metabolic rate, a result of the body's attempts to conserve energy.

  • Without enough energy to fuel its metabolic fire, core body temperature will drop, and hypothermia may develop.

  • Starvation can cause high cholesterol levels, although this is NOT an indication to restrict dietary fats, lipids, and/or cholesterol.

Other Health Consequences

  • Low caloric and fat consumption can cause dry skin and hair to become brittle and fall out.

  • To conserve warmth during periods of starvation, the body will grow fine, downy hair called lanugo.

  • Severe, prolonged dehydration can lead to kidney failure.

  • Inadequate nutrition can decrease the number of certain types of blood cells.

  • Anemia develops when there are too few red blood cells or too little iron in the diet. Symptoms include fatigue, weakness, and shortness of breath.

  • Malnutrition can also decrease infection-fighting white blood cells.

Treatment Options

The first step to recovery is recognizing the problem. Treatment will work better when the patient accepts they have BN. The main point of treatment is to recover standard eating patterns and weight. It is recommended that the entire family participate in therapy; for some patients, BN is a lifelong battle.


Therapy options can be done in a one-on-one setting, with family, or in a group. The most common one-on-one option is Cognitive Behavioral Therapy (CBT). It helps the individual change thoughts and behavior; CBT helps the individual cope with emotions and self-esteem. The family therapy option is to resolve disputes. A therapist can help a family develop healthy eating habits along with a better understanding of bulimia. The last option is group therapy, where multiple individuals with BN meet to discuss their struggles. It is often lead by a medical professional.


There is currently no medication to treat bulimia nervosa. However, there is medication to treat some of the underlying causes or co-existing mental health disorders that often accompany BN. These include depression and anxiety. The FDA has approved Prozac to treat bulimia, and doctors may prescribe other antidepressants to treat BN.


Hospitalization may be required if malnutrition and dehydration are extreme; when needed, a feeding tube or intravenous fluid may be administered. If an individual still refuses to eat, long-term hospitalization may be required.

Individuals might require more than one therapy option.

Book: Clinical Handbook of Complex and Atypical Eating Disorders

Author: Anderson, L.K.; Murray, S.B.; Kaye, W.H.

Publish Date: September 26, 2017

Price: $69 (Paperback)

Description: "Clinical Handbook of Complex and Atypical Eating Disorders brings together into one comprehensive resource what is known about an array of complicating factors for patients with ED, serving as an accessible introduction to each of the comorbidities and symptom presentations highlighted in the volume. The first section of the book focuses on the treatment of ED in the presence of various comorbidities, and the second section explores the treatment of ED with atypical symptom presentations. The third section focuses on how to adapt ED treatments for diverse populations typically neglected in controlled treatment trials: LGBT, pediatric, male, ethnically diverse, and older adult populations. Each chapter includes a review of clinical presentation, prevalence, treatment approaches, resources, conclusions, and future directions. Cutting edge and practical, Clinical Handbook of Complex and Atypical Eating Disorders will appeal to researchers and health professionals involved in treating ED."

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