Bulimia nervosa

About bulimia nervosa

If you have bulimia, you have cycles of eating too much in a short period of time, often in secret. This is called binge eating or bingeing. Bingeing usually involves eating lots of high-calorie foods, commonly thought of as treats (for example, chocolate and cakes). This leads to a feeling of shame and sometimes severe anxiety.

Bingeing is followed by purging – this is when you rid yourself of the food or calories you have eaten. You may do this by vomiting or taking medicines including laxatives, diuretics (water tablets) or possibly illegal drugs called amphetamines. Alternatively, you may exercise excessively, starve yourself or use a combination of these.

About one to two women in 100 will have bulimia at some point in their lives. Bulimia most often develops in women in their late teens to early twenties, but it can occur at any age in men or women. Bulimia is less common in men – fewer than one man in 100 gets the condition.

If you have bulimia, you will usually be within the healthy weight range for your height. The other main eating disorder is anorexia nervosa, which is characterised by excessive weight loss. Some people with bulimia have had, or develop, anorexia.

Symptoms of bulimia nervosa

Bulimia has many symptoms, some of which are related to how you think and behave and others that are physical. Behavioural symptoms of bulimia include:

  • not eating with others or going to the toilet after meals to vomit the food you have eaten
  • having a binge-purge cycle at least twice a week for three months or more
  • secretly hoarding food
  • being obsessed with dieting and exercise
  • becoming secretive and unwilling to socialise
  • self-harming, such as scratching or cutting yourself

If you have bulimia, you’re preoccupied with thoughts of food or cravings and have an intense fear of gaining weight. You may have a distorted view of your body and think you’re larger in shape than you really are. You may feel depressed and anxious, find concentrating difficult and have feelings of guilt and shame about your eating habits.

Physically, there may be no signs. Your weight may fluctuate – you most likely won’t be very underweight, and may be slightly overweight.

Other physical symptoms can include:

  • bloating and a feeling of fullness
  • tiredness and weakness
  • indigestion
  • stomach pains
  • sore throat (from vomiting)
  • constipation or diarrhoea
  • irregular periods
  • dehydration
  • fainting

Complications of bulimia nervosa

Over time, bulimia can lead to various physical problems. These can include the following.

  • You may develop tooth decay, discoloured teeth, gum disease and bad breath caused by stomach acid in your mouth from regular vomiting – it’s important to see a dentist to reduce long-term effects.
  • You may also have patches of rough skin on your knuckles or fingers if you use them to make yourself sick.
  • Vomiting can also cause you to have a puffy face around your jaw because your salivary glands in your mouth, which produce saliva, become swollen.
  • Loss of water caused by frequent vomiting can lead to kidney damage and kidney stones.
  • Acid in vomit can cause inflammation of your stomach and oesophagus (the tube leading from your mouth to your stomach).
  • Vomiting can upset the levels of salts in your blood and lead to damage to your heart and palpitations (irregular heart beat).
  • Regularly using laxatives can cause swollen fingers.
  • Your skin may be in a poor condition and be very dry, and you may have hair loss.
  • Your bowel muscles can be damaged because of using laxatives.

It's important to get treatment for bulimia to reduce the risk of these complications.

Causes of bulimia nervosa

It isn't clear why some people develop bulimia. The reasons are probably different for everyone and may be emotional, physical or social.

The following emotional or mental health conditions are also associated with bulimia.

  • Low self-esteem – this is not thinking highly about your self-worth and associating it with your body weight.
  • Mental illness, particularly depression – bulimia may begin as a way of managing your unhappiness.
  • Obsessive-compulsive disorder – this is a condition that causes anxiety because of obsessively thinking about things or doing certain actions.
  • If you’re a perfectionist by nature, an eating disorder may give you a sense of control and achievement.

There are certain other factors that may make it more likely that you will develop bulimia, for example:

  • a family history of eating disorders – this could be a result of genetic factors or copying the behaviour of other family members
  • a specific emotionally stressful event, such as divorce, leaving home or an abusive family relationship
  • living in a Western society
  • being influenced by media images of thinness
  • having type 1 diabetes
  • having had anorexia
  • being on lots of weight-loss diets in the past

Diagnosis of bulimia nervosa

Getting help is very important. Admitting you have a problem is the first step, though it can be the hardest. Making that move means you’re more likely to be able to find the support and treatment you need to overcome bulimia and improve your life.

Talk to your GP first. He or she will ask about your life and eating habits, and will examine you to check for any physical problems resulting from bulimia.

Your GP may refer you to a psychiatrist or psychologist who is trained in the treatment of eating disorders.

Treatment of bulimia nervosa

You should start treatment for bulimia as soon as you can.

Bulimia is a serious condition, but you can recover from it. About half to three-quarters of all people treated for bulimia completely recover, but it can be a long process and happen slowly over months or years. In times of stress, you may relapse. Even if bulimia doesn’t go away completely, treatment can help you binge and purge less, which can help make you feel better and healthier. For treatment to work, you must want to get better.

Self-help

Bulimia can sometimes be treated by a self-help programme with guidance from a therapist. This treatment allows you to develop skills that will help you to manage your bulimia.

Keeping a diary of eating habits and learning about healthy eating and sensible weight control may be helpful.

Support groups may help. It can be comforting to talk to other people who may have had similar feelings and experiences. Family members may also find it useful to attend self-help meetings for relatives and carers.

Talking therapies

A type of talking treatment, or psychotherapy, called cognitive behavioural therapy (CBT) is often used. CBT can help you to learn healthier ways of thinking about food and rebuild your self-esteem. You're likely to have between 16 and 20 sessions, each lasting about an hour, over four to five months. In between sessions, you will be set tasks to do, such as making small changes to your eating habits or keeping a diary of what you eat and when.

Interpersonal therapy (IPT) is another talking treatment that allows you to discuss your relationships with other people. Rebuilding these relationships may stop you turning to food for emotional support. This kind of therapy usually takes longer.

Dietary advice

You may see a dietitian for help and advice with healthy eating. This will help you get into a steady pattern of eating without bingeing, vomiting or purging so you can maintain a healthy weight. A dietitian will also help you understand what a healthy weight is for your height and why.

Medicines

Your GP may prescribe you a type of antidepressant medicine called a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine, to treat depression in the short term. Antidepressants can reduce the urge to binge and purge, improving your symptoms in two to three weeks. However, there is no clear evidence that they can treat eating disorders long-term, so you will need other help too.

Hospital treatment

Most people who have bulimia don't need to go into hospital. But if you have serious health problems that put your life at risk, or if you're at risk of suicide or self-harm, you may need to be admitted to hospital.

Help and support

It's upsetting for loved ones to see you putting your health at risk and it's natural that they will want to help, even though you may see this as them putting you under unwanted pressure or criticising you, which makes matters worse.

You may wish to make your own choices but may need a great deal of support. If you recognise that you have a problem, others may be able to offer help with practical matters such as finding medical help and support groups.

How can I recognise if someone I know has bulimia nervosa?

Answer

It can be difficult to notice if someone close to you has bulimia because he or she will often go to great lengths to hide it. People with bulimia often have a healthy body weight but some have weight swings. If you're worried that a friend or relative has bulimia, there are a number of signs you can look out for.

Explanation

If a friend or relative has bulimia, you may already be aware that something is wrong. There are a number of common behaviours that people with bulimia show, but it's important to remember that many of the signs of bulimia are present with other problems.

If someone you know has bulimia, he or she may do the following.

  • Talk about his or her body weight or shape, and think he or she is overweight.
  • Be preoccupied with what he or she is eating and worried about putting on weight.
  • Regularly make excuses so as not to eat with you or other people (for example by telling you that he or she has already eaten or doesn't feel hungry).
  • Go to the toilet or bathroom immediately after eating.
  • Worry about money as he or she may be spending it on food for binges or laxatives and diuretics.
  • Exercise excessively.
  • Appear tired and anxious, particularly around meal times.
  • Withdraw from social events or isolate themselves.
  • Have a puffy face from swelling of the salivary glands caused by vomiting. He or she could also have worn teeth from vomiting.
  • Be secretive about eating or shopping.

It's important that you keep an eye out for the signs of bulimia and, if you're worried about your friend or relative, you may want to get professional advice before you express your worries to him or her.

My friend has bulimia nervosa - what can I do to help?

Answer

It can be difficult to know how to help a friend who has bulimia, especially if the friend is secretive about his or her feelings. But there are a number of things you can do if someone you know has bulimia.

Explanation

It's important that you talk to your friend to get a better idea about his or her feelings towards bulimia. This will help you to understand what your friend is going through and how he or she is coping with the symptoms.

You may find it difficult to talk with your friend at first, and he or she may become aggressive or secretive. This could be because your friend is worried about being rejected or doesn't want to recognise that he or she has an eating disorder. If your friend acknowledges that he or she has bulimia, encourage him or her to seek professional help. You could find medical help and support groups on your friend's behalf. Your friend may value the support if you offer to book the appointment or accompany him or her on their first visit.

Try to make your friend feel safe and relaxed so he or she can be open with you. It's important that you express your worries in a caring and thoughtful way. Be careful not to blame your friend or imply that the bulimia is his or her fault. If your friend doesn't feel ready to talk, let him or her know that you will be supportive and continue to be a friend.

You may want to find out more information about bulimia. It can be helpful if you talk to other people who are in the same situation as you. You can talk about how it's making you feel and share your ideas of different approaches.

Don't blame your friend for his or her eating disorder, or try to persuade him or her to change. This may push your friend further away. It's important that he or she is in control of recovery. Don't rush your friend, because you may lose his or her trust. What is most important is letting him or her know that your support is always there.

Even when someone has accepted help and is being treated for bulimia, lapses are common. Recognise that this is normal and be there to support your friend through their difficult times.

I'm pregnant and I have bulimia nervosa - what can I do?

Answer

If you have bulimia while you're pregnant, you risk the health of both you and your baby. It's important that you seek medical help to reduce the risks associated with bulimia.

Explanation

Getting the correct support from health professionals and people who care for you when you’re pregnant is important. Don't be afraid to be honest and share your anxieties about your body, food or your emotions so that you can get the best advice and support.

Having bulimia during pregnancy can put your baby at risk of having a low birth weight because you won’t be absorbing nutrients properly from food – therefore, there won’t be enough to sustain you and your baby. You may be more likely to have complications during your pregnancy. You're also at risk of developing postnatal depression.

If you have bulimia and you're pregnant, you may worry about weight gain and the change in your body shape. However, you may find that your symptoms of bulimia improve during pregnancy, as you become aware of the harmful effects on your unborn baby. Try to stop vomiting and using laxatives or diuretics (water tablets) as these may affect your pregnancy.

It's important to talk to your GP and midwife and allow healthcare professionals to support you throughout your pregnancy and after you have given birth. Your GP can advise you about your pregnancy. He or she will refer you to an obstetrician (a doctor who specialises in pregnancy and childbirth) who has experience with similar pregnancies.

You may be referred to an eating disorder specialist who will work with the other medical professionals supporting you to give specific advice and medical information about bulimia.

It's important to eat a well-balanced diet during your pregnancy so that you don't put your baby at risk of poor growth and development. Speak to a dietitian about your diet during and after pregnancy. He or she will give you guidance on nutrition and can create a plan for healthy eating, and will also help you to get back to a healthy weight after you have given birth.

Having counselling during and after pregnancy may help you to manage worries you have about food, weight gain, pregnancy, motherhood and your changing body.