Bulimia Nervosa: Signs, Symptoms, and Treatment

What is bulimia?

Many of us turn to food when we’re feeling lonely, bored, or stressed. But if you have the eating disorder bulimia nervosa, overeating is more like a compulsion. Bulimia is characterized by frequent episodes of binge eating followed by extreme efforts to avoid gaining weight, often by vomiting, using laxatives, or exercising to excess.

This vicious cycle of bingeing and purging can take a toll on your body and emotional well-being. It can cause damage to your digestive system and create chemical imbalances in the body that harm the functioning of major organs, including the heart. It can even be fatal.

While it is most common among young women, bulimia can affect women and men of all ages. When you’re struggling with the eating disorder, life is a constant battle between the desire to lose weight and the overwhelming compulsion to binge eat. You don’t want to binge—you know you’ll feel guilty and ashamed afterwards—but time and again you give in. After the binge ends, panic sets in and you turn to drastic measures to “undo” your overeating, such as taking laxatives, vomiting, or going for an intense run.

No matter how trapped in this vicious cycle you feel, though, there is hope. With treatment and support, you can break the cycle, learn to manage unpleasant emotions in a healthier way, and regain control of your life.

Not all bulimics purge

It's important to note that bulimia doesn't necessarily involve purging: physically eliminating the food from your body by throwing up or using laxatives, enemas, or diuretics. If you make up for your binges by fasting, exercising to excess, or going on crash diets, this also qualifies as bulimia.

Am I bulimic?

Ask yourself the following questions. The more “yes” answers, the more likely you are suffering from bulimia or another eating disorder.

1. Are you obsessed with your body and your weight?
2. Does food and dieting dominate your life?
3. Are you afraid that when you start eating, you won't be able to stop?
4. Do you ever eat until you feel sick?
5. Do you feel guilty, ashamed, or depressed after you eat?
6. Do you vomit or take laxatives to control your weight?

Signs and symptoms of bulimia

If you've been living with bulimia for a while, you've probably “done it all” to conceal your bingeing and purging habits. It's only human to feel ashamed about having a hard time controlling yourself with food, so you most likely binge alone. If you eat a box of doughnuts, then you'll replace them so your friends or family won't notice. When buying food for a binge, you might shop at four separate markets so the checker won't guess.

But despite your secret life, those closest to you probably have a sense that something is not right.

Binge eating signs and symptoms

Lack of control over eating. Inability to stop eating. Eating until the point of physical discomfort and pain.

Secrecy surrounding eating. Going to the kitchen after everyone else has gone to bed. Going out alone on unexpected food runs. Wanting to eat in privacy.

Eating unusually large amounts of food with no obvious change in weight.

Disappearance of food, numerous empty wrappers or food containers in the garbage, or hidden stashes of junk food.

Alternating between overeating and fasting. Rarely eating normal meals; it's all-or-nothing when it comes to food.

Purging signs and symptoms

Going to the bathroom after meals. Frequently disappearing after meals to throw up. Running water to disguise the sounds of vomiting.

Using laxatives, diuretics, or enemas after eating. Or taking diet pills or using the sauna to “sweat out” water weight.

Smell of vomit. The bathroom (or even the person) may smell like vomit. May try to cover up the smell with mouthwash, perfume, air freshener, gum, or mints.

Excessive exercising. Working out strenuously, especially after eating. Typical activities include high-intensity calorie burners such as running or aerobics.

Physical signs and symptoms

Calluses or scars on knuckles or hands from sticking fingers down throat to induce vomiting.

Puffy “chipmunk” cheeks caused by repeated vomiting.

Discolored teeth from exposure to stomach acid when throwing up. May look yellow, ragged, or clear.

Not underweight. Men and women with bulimia are usually normal weight or slightly overweight. Being underweight while purging might indicate a purging type of bulimia.

Frequent fluctuations in weight, by 10 pounds or more, due to alternating episodes of bingeing and purging.

Bulimia causes and risk factors

There is no single cause of bulimia. While low self-esteem and concerns about weight and body image play major roles, there are many other contributing factors. You may have trouble managing your emotions in a healthy way and use eating as an emotional release, bingeing and purging when you feel angry, depressed, stressed, or anxious.

Causes for bulimia include:

• Poor body image. Our culture’s emphasis on thinness and beauty can lead to body dissatisfaction, particularly in young women bombarded with media images of an unrealistic physical ideal.
• Low self-esteem. Women or men who think of themselves as useless, worthless, and unattractive are at risk for bulimia. Things that can contribute to low self-esteem include depression, perfectionism, childhood abuse, and a critical home environment.
• History of trauma or abuse. Women with bulimia appear to have a higher incidence of sexual abuse. People with bulimia are also more likely than average to have parents with a substance abuse problem or psychological disorder.
• Major life changes. Bulimia is often triggered by stressful changes or transitions, such as the physical changes of puberty, going away to college, or the breakup of a relationship. Bingeing and purging may be a negative way to cope with the stress.
• Appearance-oriented professions or activities. People who face tremendous image pressure are vulnerable to developing bulimia. Those at risk include ballet dancers, models, gymnasts, wrestlers, runners, and actors.

Effects of bulimia

When you are living with bulimia, you are putting your body—and even your life—at risk. The most dangerous side effect of bulimia is dehydration due to purging. Vomiting, laxatives, and diuretics can cause electrolyte imbalances in the body, most commonly in the form of low potassium levels. Low potassium levels trigger a wide range of symptoms ranging from lethargy and cloudy thinking to irregular heartbeat and death. Chronically low levels of potassium can also result in kidney failure.

Other common medical complications and adverse effects of bulimia include:

• Weight gain
• Abdominal pain, bloating
• Swelling of the hands and feet
• Chronic sore throat, hoarseness
• Broken blood vessels in the eyes
• Swollen cheeks and salivary glands
• Weakness and dizziness
• Tooth decay and mouth sores
• Acid reflux or ulcers
• Ruptured stomach or esophagus
• Loss of menstrual periods
• Chronic constipation from laxative abuse

Source: National Women's Health Information Center

Getting help for bulimia

If you are living with bulimia, you know how scary it feels to be so out of control. Knowing that you are harming your body just adds to the fear. But take heart: change is possible. Regardless of how long you've struggled with bulimia, you can learn to break the binge and purge cycle and develop a healthier attitude toward food and your body.

Steps to bulimia recovery

Acknowledge you have a problem. The first step on the road to bulimia recovery is to admit that you have a problem. It’s not losing weight or controlling what you eat that will help you to feel better, but rather, changing your relationship to food.

Reach out for support. It can be hard to talk to someone about what your experiences with bulimia, especially if you’ve kept your issues a secret for a long time. While you may feel embarrassed, ashamed, or scared of what others will think, you need to understand that you're not alone. Talk to someone who will listen without judging you and offer you support as you work towards recovery.

Avoid people, places, and situations that trigger your urge to binge or purge. Stay away from weight-loss websites and “pro-mia” sites that promote bulimia, for example. Avoid fashion or fitness magazines, and find new friends who don’t constantly diet or talk about losing weight. You may also need to be careful when it comes to meal planning and cooking magazines and shows.

Address any underlying mood disorder. It's common for people with bulimia to also suffer from depression or anxiety. Getting help for co-existing conditions is vital to your bulimia recovery.

Bulimia treatment

To stop the cycle of bingeing and purging, it’s important to seek professional help early, follow through with treatment, and resolve the underlying emotional issues that caused your bulimia in the first place.

The advice and support of trained eating disorder professionals can help you regain your health, learn to eat normally again, and develop healthier attitudes about food and your body.

Therapy for bulimia

Because poor body image and low self-esteem lie at the heart of bulimia, therapy is an important part of recovery. It’s common to feel isolated and shamed by your bingeing and purging, and therapists can help with these feelings.

The treatment of choice for bulimia is cognitive-behavioral therapy. Cognitive-behavioral therapy targets the unhealthy eating behaviors of bulimia and the unrealistic, negative thoughts that fuel them.

The following strategies can also help you on the road to bulimia recovery:

Bulimia recovery tip 1: Break the binge and purge cycle

The first step in bulimia recovery is stopping the vicious cycle of bingeing and purging. In order to do this, it's essential that you quit trying to diet. Dieting triggers bulimia's destructive cycle of bingeing and purging. The irony is that the stricter the diet, the more likely it is that you'll become preoccupied, even obsessed, with food. When you starve yourself, your body responds with powerful cravings—its way of asking for needed nutrition.

As the tension, hunger, and feelings of deprivation build, the compulsion to eat becomes too powerful to resist: a “forbidden” food is eaten; a dietary rule is broken. With an all-or-nothing mindset, you feel any diet slip-up is a total failure. After having a bite of ice cream, you might think, “I've already blown It, so I might as well go all out.”

Unfortunately, the relief that bingeing brings is extremely short-lived. Soon after, guilt and self-loathing set in. And so you purge to make up for bingeing to regain control. But purging only reinforces binge eating. Though you may tell yourself this is the last time, in the back of your mind there's a voice saying you can always throw up or use laxatives if you lose control again. However, purging doesn't come close to wiping the slate clean after a binge.

Purging does NOT prevent weight gain

Purging isn't effective at getting rid of calories, which is why most people suffering with bulimia end up gaining weight over time. Vomiting immediately after eating won't eliminate more than 50% of the calories consumed— usually much less. This is because calorie absorption begins the moment you put food in the mouth. Laxatives and diuretics are even less effective. Laxatives get rid of only 10% of the calories eaten, and diuretics none at all. You may weigh less after taking them, but that lower number on the scale is due to water loss, not true weight loss.

Tip 2: Develop a healthier relationship to food

Once you stop trying to restrict calories and follow strict dietary rules, you will no longer be overwhelmed with cravings and thoughts of food. By eating normally, you can break the binge-and-purge cycle and still reach a healthy, attractive weight.

Pay attention to your hunger. Don't wait until you're starving. This only leads to overeating! Eat as soon as you notice you're feeling moderately hungry.

Eat regularly. Don't skip meals. Try not to let over 4 hours pass without a meal or snack.

Don't restrict foods. When something is off limits, it becomes more tempting. Instead of saying “I can never eat ice cream,” say “I will eat ice cream as an occasional treat.”

Focus on what you're eating. How often have you binged in an almost trance-like state, not even enjoying what you're consuming? Instead of eating mindlessly, be a mindful eater. Slow down and savor the textures and flavors. Not only will you eat less, you'll enjoy it more.

Tip 3: Learn to tolerate unpleasant feelings

While bingeing is often triggered by overly strict dieting that backfires, it can also be a way to control or numb unpleasant moods or feelings.

The next time you feel the urge to binge, ask yourself if there's something else going on. Is there an intense feeling you're trying to avoid? Are you eating to calm down, comfort yourself, or to relieve boredom? If so, instead of using food as a distraction, take a moment to stop whatever you're doing and investigate what's going on inside.

Identify what you're feeling. Is the emotion anxiety? Shame? Hopelessness? Anger? Loneliness? Fear? Emptiness?

Accept the emotion. Trying to avoid or resist a negative emotion only makes it stronger. Instead, simple accept the emotion you're feeling without judging or beating yourself up.

Explore the emotion. Investigate what's going on with the feeling you’re experiencing. Where exactly do you feel it in your body? What are you thinking as you explore the emotion? Be curious without trying to change anything.

Remember: you are NOT your feelings. They don't define who you are. Emotions are passing events, like clouds moving across the sky. If you accept an unpleasant emotion rather than fighting it, it will soon move on.

Sitting with your feelings may feel extremely uncomfortable at first. Maybe even impossible. But as you resist the urge to binge, you'll start to realize that you don't have to give in. Even emotions that feel intolerable are only temporary. They'll quickly pass if you stop fighting them. You're still in control. You can choose how to respond.

Tip 4: Challenge dysfunctional thoughts

The bingeing and purging of bulimia is often fueled by dysfunctional, self-sabotaging ways of thinking that undermine your confidence, color everything in an unrealistically negative light, and make you feel helpless, inadequate, and ashamed. But you can learn to put a stop to these unhealthy mental habits.

Damaging mindsets that fuel bulimia

All-or-nothing thinking. Everything is black or white, there are no shades of gray, at least when thinking about yourself. If you're not absolutely perfect all of the time, then you see yourself as a total failure and might as well binge.

Emotional reasoning. You convince yourself that if you feel a certain way, it must be true. “I feel fat” means “I am fat.” “I feel like a failure” means you'll never overcome your problems.

Musts and must-nots. You hold yourself to a very rigid set of rules (“I must not eat this type of food,” “I must get straight A's,” “I must always be in control.”). You then beat yourself up if you break them.

Labeling. You label yourself derogatory names for your perceived shortcomings, or whenever you make the smallest mistake. “I'm  not happy with my weight” becomes: “I'm vile, disgusting.” A backslide in recovery becomes: “I'm useless, a total failure.”

Catastrophizing. You instantly assume the worst. If you slip up in recovery, for example, you assume that you’re doomed to be this way forever and there's no hope you'll ever get better.

Challenge these destructive thoughts

When you identify the damaging mindsets that fuel your bulimia, you can challenge them by asking yourself questions such as:

• “Is there any evidence that this thought is true? Or not true?”
• “If a friend had this thought, what would I tell them?”
• “Is there another way of looking at my situation? Is there a more likely explanation?”
• “If I didn't have bulimia, how would it change how I see the situation?”

As you put your negative thoughts on the witness stand, you’ll see just how quickly they start to fall apart. The more you challenge these negative thoughts, the better you’ll be able to develop a more balanced way of thinking.

Helping someone with bulimia

If you suspect that your friend or family member has bulimia, talk to the person about your concerns. Your loved one may deny bingeing and purging, but there's a chance that he or she will welcome the opportunity to open up about the struggle.

Either way, bulimia should never be ignored. The person's physical and emotional health is at stake. While you can't force anyone to get better, there are things you can do to help.

[Read: Helping Someone with an Eating Disorder]

If your loved one has bulimia

Offer compassion and support. Keep in mind that the person may get defensive or angry. But if he or she does open up, listen without judgment and make sure the person knows you care.

Avoid insults, scare tactics, guilt trips, and patronizing comments. Since bulimia is often caused and exacerbated by stress, low self-esteem, and shame, negativity will only make it worse.

Set a good example for healthy eating, exercising, and body image. Don't make unpleasant comments about your own appearance or anyone else's.

Accept your limits. There isn't a lot you can do to “fix” your loved one's bulimia. The person with bulimia must make the decision to move forward.

Take care of yourself. Know when to seek advice for yourself from a counselor or health professional. Dealing with an eating disorder is stressful, and it will help if you have your own support system in place.

Last updated or reviewed on October 11, 2023