Bulimia nervosa: what it is, signs and symptoms, and treatment

The NHS calls bulimia an eating disorder and a serious mental health condition that can affect anyone, adding that treatment may take time but that you can recover. Beat, the UK eating disorder charity, describes people with bulimia as caught in a cycle of eating large quantities of food and then trying to compensate by vomiting, taking laxatives or diuretics, fasting, or exercising excessively.

Beat distinguishes this from ordinary overindulgence. During a binge, it says, a person does not feel in control of how much or how quickly they are eating, and some describe feeling disconnected from what they are doing. Binge eating is often a way of coping with difficult emotions such as stress, upset or anger, and the episodes are usually very distressing, with guilt and shame afterwards. People with bulimia place strong emphasis on weight and shape and may see themselves as much larger than they are.

Not everyone fits the textbook pattern. Beat explains that if symptoms do not exactly match the diagnostic criteria, for example if binge and purge cycles are less frequent than expected, the diagnosis may be other specified feeding or eating disorder (OSFED), which it says is as serious as any other eating disorder and just as important to treat quickly.

The NHS lists the main signs as losing control of how much you are eating over a very short time and getting rid of the extra food, plus a wider set of emotional and behavioural features:

• fear of putting on weight, and obsessing about or being very critical of weight and body shape

• excessive exercising

• mood changes, including feeling tense, irritable, anxious or depressed

• thinking about food a lot and planning binges

• guilt, shame and secrecy about eating habits, and avoiding social activities that involve food

The NHS lists physical signs including tiredness and trouble sleeping, feeling weak or dizzy, a sore throat from being sick, bloating or tummy pain, puffy sides of the face and under the ears from swollen glands, and irregular or stopped periods. Beat adds constipation, swelling of the hands and feet, poor skin condition, tooth damage, calluses on the backs of the hands if fingers are used to cause vomiting, an imbalance in electrolytes, and blood sugar swings that can lead to mood swings and fainting.

The NHS says bulimia can eventually lead to physical problems from missing nutrients, repeated vomiting or overuse of laxatives, and that without support it can sometimes be life-threatening. Possible complications it names are damage to teeth from stomach acid, damage to the lining of the throat, irregular or absent periods, seizures, heart or kidney problems, bowel problems including constipation, and weakened bones (osteopenia). Beat says many of the physical effects are reversible, or can be stopped from getting worse, with the right treatment.

A GP will ask about eating habits, feelings and physical symptoms, and may ask to weigh you. The NHS states that you can tell your GP if you do not want to know your weight. If a GP thinks you have bulimia or another eating disorder, they refer you to an eating disorder specialist or team. The NHS suggests bringing someone you trust to the appointment.

NICE tells professionals not to rely on screening questionnaires such as SCOFF as the only way to decide whether someone has an eating disorder. When deciding whether to refer, it asks them to consider factors such as rapid weight loss, restrictive eating, social withdrawal from situations involving food, other mental health problems, problems managing a chronic illness such as diabetes or coeliac disease, menstrual disturbances and signs of compensatory behaviour such as laxative or diet pill use. NICE also says people with eating disorders should be assessed and receive treatment at the earliest opportunity, and notes that the risk is highest for young men and women between 13 and 17.

The NHS says treatment is tailored, can last several months or years, and includes support for any other problems such as anxiety or depression. Its main treatments are talking therapies, medicines such as antidepressants if there is a closely linked condition like anxiety or depression, and support from a dietitian. Appointments are usually at a clinic, but a stay in hospital may be needed if there are serious health problems or concerns about self-harm or suicide.

NICE gets more specific. For adults it advises considering guided self-help built on cognitive behavioural materials, supported by brief sessions (it gives 4 to 9 sessions of 20 minutes over 16 weeks as an example). If that is unacceptable, ineffective after 4 weeks or contraindicated, it advises considering individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), typically up to 20 sessions over 20 weeks. For children and young people it advises offering bulimia-nervosa-focused family therapy, typically 18 to 20 sessions over 6 months, with CBT-ED as an alternative.

NICE says not to offer medication as the sole treatment for bulimia nervosa, and it advises explaining to everyone with the condition that psychological treatments have a limited effect on body weight. The NHS mentions antidepressants where another condition such as depression or anxiety is closely linked. Any prescription decision belongs with the treating clinician.

The NHS suggests several things that may help while recovering:

• spending less time looking in mirrors or checking your body, and avoiding weighing yourself

• avoiding websites and social media that encourage weight loss or a very low body weight

• trying to distract yourself after meals if you are worried about purging, for example with a new hobby that needs concentration

• rinsing your mouth with water or a non-acidic mouthwash after vomiting, and seeing a dentist regularly

• not eating or drinking acidic foods such as fruit juice during a binge or after purging, and not smoking

• talking to people you trust or finding a support group, or writing your feelings down if talking is difficult

NICE says that although eating disorders can develop at any age, the risk is highest for young men and women between 13 and 17 years of age. For children and young people with bulimia nervosa, NICE advises offering bulimia-nervosa-focused family therapy, and the NHS notes that family may also be involved in talking therapy if you are under 18.

The NHS advises people who are pregnant to tell their midwife and GP if they have an eating disorder or have had one in the past, so they can be offered the right support during and after pregnancy. NICE says a dedicated professional such as a GP or midwife should be nominated to monitor and support pregnant women with an eating disorder.

The NHS lists eating lots of food over a short period, hiding food or eating in secret, going to the bathroom a lot after eating, and excessive or obsessive exercise as possible signs in someone else, and suggests encouraging them to speak to their GP. Beat says people around someone with bulimia will probably notice changes to mood and feelings before any physical change, and that people with bulimia are often reluctant to seek help. Pregnant women with a current or past eating disorder are advised by the NHS to tell their midwife and GP so they can be offered the right support.

If someone is in immediate danger or you need urgent help in a mental health crisis, the NHS page directs people to its guidance on where to get urgent help for mental health, and in an emergency you should call 999.