Bulimia nervosa

Bulimia, also called bulimia nervosa, is an eating disorder. It involves repeated episodes of binge eating followed by actions intended to prevent weight gain.

During a binge, a person eats an unusually large amount of food within a limited period and feels unable to stop or control the eating. Afterward, they may make themselves vomit, misuse laxatives or water pills like furosemide or hydrochlorothiazide, fast, or exercise excessively. These actions are called compensatory behaviors. When they involve vomiting or medication misuse, they are often called purging.

Bulimia is not a choice or a lack of willpower. It is a mental health condition that can affect physical health, emotions, relationships, school, and work. People of any age, gender, body size, race, or background can develop it. A person with bulimia may have a weight that appears typical, so the condition is often not visible to others.

Repeated bingeing and purging can disrupt the body's balance of fluids and minerals called electrolytes. It can also damage the teeth, digestive system, kidneys, and heart. Early treatment can reduce these risks. Recovery is possible, although progress may take time and setbacks can occur.

Bulimia symptoms may be behavioral, emotional, or physical. People often hide their symptoms because of shame, fear, or concern about being judged.

Possible eating-related signs include:

• Repeated episodes of eating large amounts while feeling out of control
• Self-induced vomiting or misuse of laxatives, enemas, or water pills
• Fasting, strict dieting, or excessive exercise after eating
• Frequent trips to the bathroom during or soon after meals
• Keeping binge food hidden or eating in secret
• Strong concern about body shape or weight
• Self-worth that depends heavily on appearance or weight
• Feeling guilt, distress, or shame after eating

Physical signs can include tiredness, dizziness, dehydration, bloating, reflux, constipation, or abdominal discomfort. Some people develop swelling around the cheeks or jaw because vomiting can irritate the salivary glands. Stomach acid may wear away tooth enamel, causing tooth sensitivity, discoloration, or cavities.

Other possible signs include sore throat, hoarseness, calluses on the knuckles, irregular menstrual periods, feeling cold, or changes in sleep and concentration. Mood symptoms such as anxiety, depression, irritability, or social withdrawal may occur alongside the eating disorder.

Not everyone has every symptom. The frequency of bingeing and compensatory behavior can also change over time.

Bulimia does not have one cause. It usually develops through a combination of biological, psychological, family, and social factors.

Genes may affect vulnerability to eating disorders. Brain systems involved in appetite, reward, impulse control, and mood may also play a role. Having a close relative with an eating disorder or certain other mental health conditions may increase risk, but it does not mean someone will develop bulimia.

Dieting or regularly skipping meals can contribute to a binge-and-restrict cycle. Hunger builds, a binge occurs, and the person then tries to compensate by purging or restricting food again. This can strengthen the cycle.

Other associated factors may include:

• Anxiety, depression, obsessive-compulsive symptoms, or substance use
• Perfectionism, impulsivity, or difficulty managing intense emotions
• Bullying, weight stigma, trauma, or major life changes
• Pressure to meet narrow body or performance standards
• Activities that emphasize weight, appearance, or a specific body type
• A history of another eating disorder

These factors do not prove why bulimia developed. Avoiding blame is important. Families do not cause eating disorders, but supportive family members can play a valuable role in recovery.

There is no single laboratory test for bulimia. A clinician makes the diagnosis by discussing eating patterns, feelings about food and body image, and compensatory behaviors. They may also ask about mood, anxiety, substance use, self-harm, and the effect of symptoms on daily life.

Clinical diagnostic criteria include repeated binge-eating episodes with a sense of lost control, repeated behaviors intended to prevent weight gain, and excessive influence of body shape or weight on self-evaluation. These episodes generally occur at least weekly for three months. A clinician also considers whether the symptoms occur only during anorexia nervosa.

An evaluation usually includes a medical history, medication review, and physical examination. The clinician may check blood pressure, pulse, temperature, hydration, and changes in weight over time. Weight alone cannot confirm or rule out bulimia.

Blood or urine tests may be used to look for dehydration, kidney problems, or abnormal electrolytes such as potassium. An electrocardiogram, or ECG, may be recommended to check heart rhythm. Additional testing depends on the person's symptoms and medical condition.

A dental examination can identify acid-related enamel damage. Clinicians may also assess menstrual or reproductive health when relevant.

It is important to answer questions as honestly as possible. Accurate information helps the care team assess medical safety and select appropriate treatment. A person does not need to meet every diagnostic criterion to deserve care; other specified eating disorders can cause serious distress and medical problems.

Treatment is based on age, symptoms, medical stability, other health conditions, and available support. Care may involve a primary care clinician, mental health professional, registered dietitian with eating-disorder experience, and dentist.

The first priority is medical safety. Significant dehydration, severe electrolyte abnormalities, an unstable heart rhythm, or an inability to stop frequent purging may require treatment in a hospital or specialized eating-disorder program. Many people can be treated through outpatient appointments when they are medically stable.

Nutrition treatment focuses on establishing regular, adequate meals and snacks. This reduces extreme hunger and helps interrupt the binge-and-restrict cycle. A dietitian may help the person recognize rigid food rules, plan balanced eating, and respond to urges without compensating. Treatment should not center only on weight.

Psychotherapy is a central part of care. Cognitive behavioral therapy adapted for eating disorders helps identify patterns connecting thoughts, emotions, eating, and compensatory behavior. It also works on regular eating, body-image concerns, and relapse prevention. Guided self-help based on cognitive behavioral methods may be offered in some settings.

For adolescents, family-based treatment adapted for bulimia may be considered. It involves parents or caregivers in supporting regular eating and reducing harmful behaviors without blaming the young person. Other therapies may help when emotional regulation, trauma, relationship problems, or another mental health condition needs attention.

Medication may sometimes be used with psychotherapy. Fluoxetine, a selective serotonin reuptake inhibitor, is approved by the U.S. Food and Drug Administration for adults with bulimia. It may help reduce binge-eating and vomiting episodes. Medication choice requires a clinician's review because benefits and risks differ by person, and medication should not replace nutritional and psychological care.

Bupropion is generally contraindicated in people who currently have or previously had bulimia because of an increased seizure risk. Anyone taking it should speak with the prescriber rather than stopping it on their own.

Dental care can limit further damage but cannot restore enamel that has already been lost. After vomiting, rinsing the mouth with water can help clear acid. Brushing immediately may wear down acid-softened enamel, so a dentist can advise when and how to brush and whether fluoride treatment is appropriate.

Recovery usually involves reducing and stopping bingeing and compensatory behaviors, improving physical health, and building a more flexible relationship with food and body image. Treatment may also address depression, anxiety, substance use, or other conditions that could affect recovery.

Repeated vomiting can cause dehydration and loss of electrolytes. Low potassium can interfere with muscle function and heart rhythm. Severe electrolyte problems may become medically dangerous even when a person does not look unwell.

Stomach acid can inflame the throat and esophagus, the tube connecting the mouth to the stomach. Possible effects include reflux, pain, bleeding, or small tears. Forceful vomiting rarely causes a major tear. Bloating, constipation, and delayed stomach emptying may also occur.

Laxatives do not remove most calories from food. Misuse can cause dehydration, electrolyte changes, kidney injury, and worsening constipation. Water pills mainly remove fluid and may also disturb electrolyte balance.

Additional complications can include:

• Tooth enamel erosion, cavities, and gum problems
• Swollen or painful salivary glands
• Kidney problems related to dehydration
• Irregular menstrual periods or reproductive health changes
• Weakness, fainting, or difficulty concentrating
• Depression, substance-related problems, self-harm, or suicidal thoughts

These complications are not inevitable. Medical monitoring and treatment can prevent some problems and allow others to improve.

Follow-up is usually more frequent early in treatment. Appointments may track bingeing and compensatory behaviors, hydration, pulse, blood pressure, laboratory results, mood, and progress with regular eating. Dental follow-up may be needed when vomiting has affected the teeth.

Recovery is rarely perfectly linear. Increased urges or a return of symptoms does not mean treatment has failed. Contacting the care team early can help prevent a brief setback from becoming a longer relapse.

Arrange a prompt appointment if bingeing or purging is occurring, symptoms are increasing, or dizziness, weakness, dental damage, reflux, or menstrual changes develop. A clinician should also review any laxative, water-pill, supplement, or medication use.

Seek urgent or emergency care for:

• Fainting, a seizure, confusion, or severe weakness
• Chest pain, trouble breathing, or a rapid or irregular heartbeat
• Vomiting blood, black stools, or severe abdominal pain
• Inability to keep fluids down or signs of severe dehydration
• Thoughts of suicide, a suicide plan, or concern about immediate safety

In the United States, a person in a suicidal or mental health crisis can call or text 988. Elsewhere, use the local emergency number or crisis service.