Bulimia

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Introduction

Bulimia

Bulimia is an eating disorder and mental health condition. 

People who have bulimia go through periods where they eat a lot of food in a very short amount of time (binge eating) and then are deliberately sick, use laxatives (medication to help them poo) or do excessive exercise, or a combination of these, to try to stop themselves gaining weight.

Men and women of any age can get bulimia, but it's most common in young women and typically starts in the mid-to-late teens.

Symptoms of bulimia

Symptoms of bulimia include:

  • eating very large amounts of food in a short time, often in an out-of-control way - this is called binge eating
  • making yourself vomit, using laxatives or doing an extreme amount of exercise after a binge to avoid putting on weight - this is called purging
  • fear of putting on weight
  • being very critical about your weight and body shape
  • mood changes - for example, feeling very tense or anxious

These symptoms may not be easy to spot in someone else because bulimia can make people behave very secretively.

Read more about the symptoms of bulimia and warning signs in others.

Getting help for bulimia

Getting help and support as soon as possible gives you the best chance of recovering from bulimia.

If you think you may have bulimia, see your GP as soon as you can.

They will ask you questions about your eating habits and how you're feeling, and will check your overall health and weight. 

If they think you may have bulimia, or another eating disorder, they should refer you to an eating disorder specialist or team of specialists.

It can be very hard to admit you have a problem and to ask for help. It may make things easier if you bring a friend or loved one with you to your appointment.

You can also talk in confidence to an adviser from eating disorders charity Beat by calling its adult helpline on 0808 801 0677 or youth helpline on 0808 801 0711.

Getting help for someone else

If you're concerned that a family member or friend may have bulimia, let them know you're worried about them and encourage them to see their GP. You could offer to go along with them.

Read more about talking to your child about eating disorders and supporting someone with an eating disorder.

Treatment for bulimia

You can recover from bulimia, but it may take time and recovery will be different for everyone.

Your treatment plan will be tailored to you and should take into account any other support you might need, such as for depression or anxiety.

If you are over 18, you will probably be offered a guided self-help programme. This involves working through a self-help book, and often includes keeping a diary and making a plan for your meals. You will be supported by a therapist during this process. You may also be offered cognitive behavioural therapy (CBT).

If you are under 18, you may be offered family therapy as well as CBT.
Read more about the treatments for bulimia.

Health risks of bulimia

Bulimia can eventually lead to physical problems associated with not getting the right nutrients, vomiting a lot or overusing laxatives.

Possible complications include:

  • feeling tired and weak
  • dental problems - stomach acid from persistent vomiting can damage tooth enamel and also cause bad breath, a sore throat or even tears in the lining of the throat
  • irregular or absent periods
  • dry skin and hair
  • brittle fingernails
  • swollen glands
  • fits and muscle spasms
  • heart, kidney or bowel problems, including permanent constipation
  • bone problems - you may be more likely to develop issues problems such as osteoporosis, particularly if you have had symptoms of both bulimia and anorexia

Causes of bulimia

We don't know exactly what causes bulimia and other eating disorders. You may be more likely to get an eating disorder if:

  • you or a member of your family has a history of eating disorders, depression, or alcohol or drug addiction
  • you have been criticised for your eating habits, body shape or weight
  • you are overly concerned with being slim, particularly if combined with societal pressure to be slim or from your job - for example, ballet dancers, jockeys, models or athletes
  • you have anxiety, low self-esteem, an obsessive personality or are a perfectionist
  • you have been sexually abused

Binge-purge cycle

Bulimia is often a vicious cycle of binging and purging, triggered by things such as hunger, sadness or stress.

You may set very strict rules for yourself about dieting, eating or exercising. Failing to keep to these then leads to periods of excessive eating and loss of control (binge eating), after which you feel guilty or ashamed. You then purge to get rid of the calories, leaving you feeling hungry again, and the cycle continues.


Symptoms

Symptoms

The main signs of bulimia are eating a large amount of food over a very short time (binge eating) and then ridding your body of the extra food (purging) by making yourself vomit, taking laxatives or exercising excessively, or a combination of these.

Other signs of bulimia include: 

  • fear of putting on weight
  • being very critical about your weight and body shape
  • mood changes - feeling very tense or anxious, for example 
  • thinking about food a lot
  • feeling guilty and ashamed, and behaving secretively
  • avoiding social activities that involve food
  • feeling like you have no control over your eating

You may also notice physical signs like:

  • feeling tired
  • a sore throat from being sick
  • bloating or tummy pain
  • a puffy face
  • self-harming

Warning signs of bulimia in someone else

The following warning signs could indicate that someone you care about has an eating disorder:

  • eating a lot of food, very fast
  • going to the bathroom a lot after eating, often returning looking flushed
  • excessively or obsessively exercising

Treatment

Treatment

Treatment may take time but you can recover from bulimia.

Treatment for bulimia is slightly different for adults and those under 18 years old.

Treatment for adults

Guided help

You will probably be offered a guided self-help programme as a first step in treating your bulimia. This often involves working through a self-help book combined with sessions with a health care professional, such as a therapist.

These self-help books may take you through a programme that helps you to:

  • Monitor what you are eating: this can help you notice and try to change patterns in your behaviour
  • Make realistic meal plans: planning what and when you intend to eat throughout the day can help you regulate your eating, prevent hunger and reduce binge eating.
  • Learn about your triggers: this can help you to recognise the signs, intervene and prevent a binge-purge cycle.
  • Identify the underlying causes of your disorder: this means you can work on those issues in a healthier way.
  • Find other ways of coping with your feelings.

Joining a self-help support group, like one of the Beat online support groups for people with bulimia, may be helpful to you.

If self-help treatment alone isn't enough or hasn't helped you after four weeks, you may also be offered cognitive behavioural therapy (CBT) or medication.

Cognitive behavioural therapy

If you are offered CBT, it will usually involve up to 20 sessions across 20 weeks.

CBT involves talking to a therapist, who will help you explore emotions and thoughts that could be contributing to your eating disorder, and how you feel about your weight and body shape. 

They will help you to adopt regular eating habits and show you how to stick to them. They should also show you ways to manage difficult feelings and situations to stop you from relapsing once your therapy ends.

Treatment for children and young people

Family therapy

Children and young people will usually be offered family therapy. This involves you and your family talking to a therapist, exploring how bulimia has affected you and how your family can support you to get better.

You may also be offered CBT, which will be the same as the CBT offered to adults.

Looking after yourself

It's important to look after your health while recovering from bulimia.

If you are vomiting regularly, the acid in your vomit can damage your teeth over time. In order to minimise this damage you should:

  • avoid brushing teeth immediately after vomiting so you don't wear away the enamel
  • rinse your mouth with a non-acidic mouthwash
  • make sure you see your dentist regularly
  • don't drink or eat acidic foods, such as fruit juice, during a binge and after purging
  • don't smoke

Vomiting can also lead to risk of dehydration. To avoid this, make sure you drink plenty of fluids to replace what you have vomited.

Medication

Antidepressants should not be offered as the only treatment for bulimia. But you may be offered an antidepressant, such as fluoxetine (Prozac), in combination with therapy or self-help treatment, to help you manage other conditions, such as: 

Antidepressants are very rarely prescribed for children or young people under 18.

Where treatment will happen

Most people with bulimia will be able to stay at home during their treatment. You will usually have appointments at your clinic and then be able to go home.

However, you may be admitted to hospital if you have serious health complications, including:

  • being very underweight
  • problems with your heart
  • being very ill and your life being at risk
  • being under 18 and your doctors believing you don't have enough support at home
  • doctors being worried that you might harm yourself or are at risk of suicide

Your doctors will keep a very careful eye on your weight and health if you're being cared for in hospital. They will help you to reach a healthy weight gradually, and either start or continue any therapy you are having.

Once they are happy with your weight, as well as your physical and mental health, you should be able to return home.

Further support for bulimia

There are many organisations that support people with bulimia and their families, including:



'Bulimia isn't a women’s disease; it’s a people's disease'

'Bulimia isn't a women’s disease; it’s a people's disease'

Steve Blacknell, 55, used to sneak into the kitchen in the middle of the night to eat in secret. He has been a recovering bulimic for 20 years.

"I think the first seeds of bulimia were sewn in 1974. I'm an ex-rugby player. I wasn't a big hairy thing, but I was quite chunky and I used to attract thin women. One day a girlfriend said I was the fattest man she'd ever been out with, and that was that.

"One of the main turning points was in 1980, when I made the transition from being a record company representative to a TV presenter. If you're bulimic, you really don't want to be in a position where the camera puts 8lbs on you. One day at lunch, I ate my starter, main course and dessert, followed by a quadruple brandy and I got rid of the lot. I weighed myself when I got home and thought it was fantastic. I could eat and drink whatever I wanted and I didn't put on any weight. But, of course, it wasn't fantastic at all. 

"I was living in north London with my friend, Maggie, who is now my wife. I wouldn't eat all day, but I'd sleep-eat at night. Maggie would often get up in the middle of the night and find me wedged in the serving hatch to the kitchen, trying to get something to eat. She started to padlock the serving hatch, but would then wake up to find me cowering over her, begging for the key. We laugh about it now, but it was pretty sad. 

"I still eat during the night. It's an odd thing, but somehow it's allowed because there's no one around and I feel it's OK to eat alone. Back then, the situation was bad, but at least I could chat to Maggie about it. I think she probably saved me.

"The thing about addiction is that it never goes away. They say an alcoholic takes each day at a time, and cigarette smokers are the same. I suppose I take it one day at a time. I still can't eat big meals in front of other people. I find that really, really hard, and my digestive tract has been badly damaged.

"Bulimia is often referred to as a women's disease, but I think it's a people's disease. I just think it may be harder for a man to go to a support group and get up and say, 'Look at me. I'm a bulimic. I throw my food up.'

"For me, nothing beats beat, the eating disorder organisation that I volunteer for. I talk not only about bulimia, but also about myself and what I went through in the hope that it can help other people. 

"There is hope and there are people you can talk to. Your situation may seem too big because you build it up, but help is out there. There is light at the end of the tunnel."

'I knew it had to stop because I was living a dual life'

'I knew it had to stop because I was living a dual life'

Liselle Terret, 38, had bulimia between the age of 14 and 23.

"I was struggling a bit at school and I wasn't very happy at home. It was classic 'middle-child syndrome', perhaps. As a young woman, I remember feeling very confused about my body.

"I then started to purge my food in the toilet. The secretiveness of it was attractive to me. It was something that was mine. Unfortunately, I became addicted to the habit of vomiting.

"It was something I didn't have to explain verbally and I think it was a way of feeling in control. I had started to use food for a little bit of comfort. It was a solitary time on my own in the toilet.

"Bulimia is known as the secret disorder. In one way, it's a coping mechanism. It happens when you can't cope and something needs to change. That's why it's a very dangerous illness to have because you carry on. I carried on in school. I did my exams (I didn't do very well, but I did them), I got into university and I went abroad for a year. All the time I was secretly vomiting.

"My teeth were decaying and my periods had stopped. I certainly didn't have any sexual relations, that totally stopped. Unfortunately, I learned to hate myself.

"It was at university that I realised I had to see somebody. I knew it had to stop because I was living a dual life. Apart from seeing a therapist, which I still do, I also went on my own journey of healing using the creative arts. I'm a lecturer and practitioner of community theatre.

"There's absolutely nothing glamorous, exciting or positive about developing an eating disorder. All it does is decay your body, and it shortens your life. I still spend a ridiculous amount of money on my teeth, which are in a bad way, and it affects fertility. More importantly, it affects how you feel about yourself. It affects your relationships with family, friends and partners. For many years, I didn't have a relationship because I was too afraid to. I was living in a terribly self-destructive way.

"The difficulty in getting help is that you can't force people with bulimia to talk about it, particularly with an illness like this. You live in denial and, for me, there was a huge shame about it. I felt that people thought it was grotesque and they didn't want to know about it. You just want to be normal and you want to fit in.

"It's an addiction. It is not a way of surviving, but the opposite. It's only when you realise that there is something wrong in your behaviour that you want to get help."

'I went into hospital with a ruptured bile duct from vomiting so much'

'I went into hospital with a ruptured bile duct from vomiting so much'

Mary Black, 48, who runs a small business in the Midlands, battled with bulimia for several years but eventually found the road to recovery.

"I think my bulimia may have had its roots in my claustrophobic upbringing. My mother had me when she was very young, and was very strict. I never thought it was right to express my feelings and kept them to myself. As a result, I grew up thinking I was never good enough. Even at school, I felt like an outsider.

"I was a normal size 12, but by the time I was 17, I was convinced that I was fat and unglamorous. I started to diet, but I just ended up getting larger. I used to starve myself for three or four days, then I would binge on anything I could lay my hands on. This was usually bread, biscuits and cereals. Then I felt so disgusted with myself that I would make myself sick as fast as I could in the hope that I would get rid of the food before I had time to digest it.

"I was still living at home and this was my secret. My parents had no idea what was going on. Even when I went into hospital with a ruptured bile duct from vomiting so much, I managed to explain it away as appendicitis.

"By the time I was 22, I decided to go on a healthy eating regime, which I managed to stick to for two or three years. But then the bulimia started again. I had just come out of a relationship and was feeling pretty low generally. I also felt my life was running away and there was no purpose to it.

"I existed like this until I was about 28, but then I met someone who was a recovering alcoholic who suggested I had an eating disorder. It suddenly dawned on me that my problems weren't about food, but about my whole attitude to life.

"I decided to look for help and started going to an Overeaters Anonymous (OA) Wednesday-night meeting, which took place about 50 miles from where I lived. It was very helpful and provided a framework for my recovery. But I quickly realised that if I wanted to recover, I had to do it myself.

"I was fed up with feeling sick and tired, so I decided to keep a diary. At the end of each day, I wrote down what had made me feel uncomfortable and the things that had happened that I had tried to soothe with food. As soon as I looked back at what I had written, I realised things weren't nearly as bad as they seemed. Gradually, I stopped whinging about things in my diary and started to write about my achievements.

"Slowly, I started to eat normally again and lose weight. I also set up a local OA meeting and have a massive attendance each week. I now feel that I am 99% free of my compulsive eating and I would not dream of vomiting.

"I am healthier now than I have ever been and just so grateful that my bulimia didn't destroy my looks. The body does heal itself and it's never too late to start on the road to recovery, but you have to take that first step yourself. Nothing is permanent and my recovery process is ongoing every day."

Causes of bulimia

Causes of bulimia

There is no simple answer to the question of what causes bulimia. Although the condition is linked to a fear of getting fat, more complex emotions usually contribute.

The act of binging and purging is often a way of dealing with these intense emotions.

Common emotional causes

Common problems that may lead to bulimia include:

  • low self-esteem - if you have an eating disorder, you may have a low opinion of yourself and see losing weight as a way of gaining self-worth
  • depression - you may use binging as a way of coping with unhappiness, but purging does not relieve this depression and the cycle continues
  • stress - for example, you may develop the condition after dealing with a traumatic experience, such as a death or divorce, or during the course of important life-changing events, such as getting married or leaving home

Bulimia can also occur in people who have experienced physical illness, and in people who have been sexually abused. Some people with bulimia have experienced a difficult childhood, with family problems, arguments and criticism.

Other mental health problems

Bulimia is often linked to other psychological problems. Research shows that bulimia is more common in people who have:

Cultural and social pressure

Some people believe that the media and fashion industries create pressure for people to aspire to low body weights.

Puberty

Many young people become affected by eating disorders around the time of puberty, when hormonal changes can make them more aware of their body.

If teenagers feel they have no say in their lives, bulimia can seem like the only way to take control.

Genetics

There may be a genetic factor related to developing bulimia. Research suggests that people who have a close relative who has or has had bulimia are four times more likely to develop it than those who do not have a relative with the condition.

Men and bulimia

The causes of bulimia in men can be slightly different. In many cases, bulimia develops because of bodybuilding or specific occupations like athletics, dancing or horse racing.

However, like many women, younger men are increasingly becoming more vulnerable to disliking their bodies and being bullied or teased as children for being overweight.

Diagnosing bulimia

Diagnosing bulimia

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your GP. You may think it is not serious, but bulimia can damage your long-term health.

Accepting that you need help and support is the first step to recovery, but this may be a very difficult step for you to take. Most people who have bulimia hide their situation for months or years before seeking help. It can often take a change of situation, such as the start of a new relationship or living with new people, to make a person with bulimia want to seek help.

It may help to make a list of questions you want to ask before you see your GP. Once you have explained your situation to your GP, they will decide whether to refer you to a specialist mental health team.

Your local team will include:

  • specialist counsellors
  • psychiatrists
  • psychologists
  • nurses
  • dietitians
  • other healthcare professionals

Your treatment depends on how serious your condition is and the best way to manage it. Your GP may recommend a self-help programme to start your recovery before referring you for specialist treatment.

You can make a full recovery from bulimia. The earlier you start treatment, the quicker the recovery process will be.

Do I have an eating disorder?

Doctors sometimes use a questionnaire called the SCOFF questionnaire to help recognise people who may have an eating disorder. This involves answering the following five questions:

  • Scoff: Do you ever make yourself vomit because you feel uncomfortably full?
  • Control: Do you worry you have lost control over how much you eat?
  • One stone: Have you recently lost more than one stone (six kilograms) in a three-month period?
  • Fat: Do you believe yourself to be fat when others say you are too thin?
  • Food: Would you say that food dominates your life?

If you answer "yes" to two or more of these questions, you may have an eating disorder.

Complications of bulimia

Complications of bulimia

There are a number of physical complications associated with bulimia.

These can include any of the following:

  • Dental problems - persistent vomiting can cause your stomach acid to damage the enamel on your teeth, which may lead to tooth decay. Excessive vomiting can also cause bad breath and a sore throat.
  • Irregular periods - your menstrual cycle can become unpredictable, or even stop altogether. You may also find it difficult to become pregnant in the future.
  • Poor skin and hair - a lack of nutrients through persistent vomiting or laxative use can make your skin and hair unhealthy. Your skin and hair can become dry and your fingernails can become brittle.
  • Swollen glands - if you have bulimia, your saliva glands can become swollen from frequent vomiting. This makes your face appear rounder.
  • Chemical imbalance - excessive vomiting and laxative use can cause chemical imbalances in your body. This can result in tiredness, weakness, abnormal heart rhythms, kidney damage, convulsions (fits) and muscle spasms.
  • Bowel problems - excessive use of laxatives can damage your bowel muscles, resulting in permanent constipation.
  • Heart problems - long-term complications of bulimia can include an increased risk of heart problems.