BULIMIA nervosa is an eating disorder and mental health condition.
People who have bulimia try to control their weight by binge eating and then purging the food from their body by being sick or using laxatives.
Eating disorders are characterised by an abnormal attitude towards food that causes someone to change their eating habits and behaviour. It can be difficult to understand how an eating disorder develops.
Everyone has their own eating habits. For example, people with a food intolerance need to avoid eating certain foods to stay healthy. However, the habits of people with eating disorders are motivated by an overwhelming fear of getting fat.
People with bulimia tend to alternate between eating excessive amounts of food (bingeing), and then making themselves sick or using laxatives (purging) to maintain a chosen weight. This is usually done in secret.
People with bulimia purge themselves because they feel guilty about the binge eating, but the bingeing is a compulsive act that they feel they cannot control.
Bulimia can affect men and women, but women are 10 times more likely to develop bulimia than men. However, bulimia is becoming more common in boys and men.
Recent studies suggest that as many as 8% of women have bulimia at some stage in their life. The condition can occur at any age, but mainly affects women aged between 16 and 40 (on average, it starts around the age of 18 or 19). Bulimia can affect children, but this is extremely rare.
The main symptoms of bulimia are binge eating and purging (ridding your body of food by making yourself sick or taking laxatives).
Binge eating is repeatedly eating vast quantities of high-calorie food, without necessarily feeling hungry or needing to eat. The urge to eat can begin as an attempt to deal with emotional problems, but can quickly become obsessive and out of control.
Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.
Sometimes, the binges are spontaneous, where you eat anything you can find at that moment. Binge eating episodes can also be planned, where you make a shopping trip to buy foods specifically to binge on.
For more information, see the Health A-Z topic on Binge eating.
Purging is a response to bingeing. After you have eaten lots of food in a short space of time, you may feel physically bloated and unattractive. You may also feel guilty, regretful and full of self-hatred.
However, the main impulse to purge is a powerful, overriding fear of putting on weight.
The most common methods of purging involve making yourself sick or using laxatives to encourage your body to pass the food quickly.
Less common methods of purging include taking diet pills, over-exercising, extreme dieting, periods of starvation or taking illegal drugs, such as amphetamines.
Bulimia is often a vicious circle. If you have the condition, it is likely that you have very low self-esteem. You may also think you are overweight, even though you maybe at or near a normal weight for your height and build.
This may encourage you to set yourself strict rules about dieting, eating or exercising, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have denied yourself. After feeling guilty about bingeing, you purge to get rid of the calories.
Other signs of bulimia can include:
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 to the problem. The act of bingeing and purging is often a way of dealing with these intense emotions.
Some common factors that may lead to bulimia are outlined below.
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.
You may use bingeing as a way of coping with unhappiness. People with bulimia often feel depressed, so they binge regularly. However, purging does not relieve this depression and the cycle continues. For more information, see the Health A-Z topic aboutDepression.
Bulimia can sometimes occur following stressful situations or life events. 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.
Bulimia is often linked with other psychological problems. Research shows that bulimia is more common in people who have anxiety disorders, obsessive compulsive disorder(OCD), post-traumatic stress disorder (PTSD) and personality disorders.
Some people believe that the media and fashion industry create pressure for people to aspire to low body weights.
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 they can take control.
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.
If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your GP.
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.
Once you have explained your situation to your GP, they will decide whether to refer you for help from a specialist mental health team. Your local team will include specialist counsellors, psychiatrists, psychologists, nurses, dietitians and other healthcare professionals.
The course of 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 recover from bulimia, but it may be a long and difficult process.
The first step towards getting better is to recognise the problem and to have a genuine desire to get well. This may involve a big change in lifestyle and circumstances.
Treatment usually begins with psychological treatments, aimed to help you re-establish healthy attitudes towards eating. People with bulimia need to explore and understand the underlying issues and feelings that are contributing to their eating disorder, and change their attitudes to food and weight.
Sometimes, your GP may suggest you try medication, usually in addition to psychological treatment.
Cognitive behavioural therapy (CBT) is the most common type of psychological treatment for bulimia. It involves talking to a therapist and looking at your emotions in detail to work out new ways of thinking about situations, feelings and food. It may also involve keeping a food diary, which will help determine what triggers your binge eating.
As with CBT, interpersonal therapy (IPT) involves meeting with a therapist to discuss your condition. However, the focus is more on your personal relationships than your problems with food.
You are more likely to be referred for this type of psychological treatment if you have recently lost a loved one and have experienced a big change in your life. The aim of IPT is to help you establish supportive relationships. This can help draw your focus away from eating.
Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may be used to treat bulimia. The SSRI usually recommended to treat bulimia is called fluxetine (brand name Prozac).
SSRIs are mainly used to treat depression, but they are also used to treat eating disorders, obsessive compulsive disorder (OCD), anxiety and social phobia.
As with any antidepressant, an SSRI will usually take several weeks before it starts to work. You will usually be started on a low dose, which is then gradually increased as your body adjusts to the medicine.
When you start taking an SSRI, see your GP after two, four, six and twelve weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.
Very few drugs are recommended for children and young people below the age of 18. It is also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.
Bulimia is not usually treated in hospital. However, if you have serious health complications and your life is at risk, you may be admitted to hospital. Hospital treatment is also considered if you are at risk of suicide or self-harm.
Once diagnosed, people with bulimia can recover, but it may take a long time. It can be very difficult, both for the person affected and their family and friends.
To recover, someone with bulimia needs to:
The longer someone has had bulimia, the harder it is to re-learn healthy eating habits and gain weight. It is important to start treatment as early as possible, so the person has the best chance of recovery.
For most people, recovery goes through several stages, where progress may be involve steps forward and steps back.
There are a number of physical complications associated with bulimia:
ANOREXIA nervosa is an eating disorder and a serious mental health condition.
People with anorexia have problems with eating. They are very anxious about their weight and keep it as low as possible by strictly controlling and limiting what they eat. Many people with anorexia will also exercise excessively to lose weight.
It is thought that people with anorexia are so concerned about their weight because they:
Even when a person with anorexia becomes extremely underweight, they still feel compelled to lose more weight.
Though people with anorexia avoid eating food whenever they can, they also develop an obsession with eating and diet. For example, they may obsessively count the calories in different types of foods even though they have no intention of eating it.
Some people with anorexia will also binge eat, i.e. they eat a lot of food in a short space of time. They then try to get rid of the food from their body by vomiting or using laxatives (medication that causes the bowels to empty; normally used for the treatment of constipation.)
The symptoms of anorexia usually begin gradually, such as adopting a restrictive diet. They then often spiral out of control quickly.
Despite being an uncommon condition, anorexia is the leading cause of mental health-related deaths.
Most cases of anorexia develop in girls and women. One in every 200 women is affected. Symptoms of anorexia usually first develop during the teenage years, at the average age of 15 (see Anorexia – symptoms for more information). But the condition can develop at any time, including childhood.
Anorexia also affects 1 in every 2,000 men. Some experts are concerned that the number of men with the condition may be increasing.
The cause of anorexia is unknown, but most experts believe the condition results from a combination of biological, psychological and environmental factors (see Anorexia – causes for more information).
The long-term malnutrition associated with anorexia can cause a range of serious complications, such as:
One of the biggest challenges in treating anorexia is that it is a condition characterised by self-denial. Many people with anorexia refuse to admit, or are unable to grasp, that there is anything wrong with them or their behaviour.
If the person is persuaded to seek help, it usually takes five to six years of treatment before they make a complete recovery, and relapses are common.
Treatment for anorexia usually involves talking therapies, such as cognitive behavioural therapy, which aim to change the person’s attitudes and behaviour. Nutritional support is also offered to help them gain weight safely.
Around 20-30% of people with anorexia do not respond to treatment, and around 5% will die from complications caused by malnutrition.
The main symptom of anorexia is losing a lot of weight deliberately. For example, by:
A person with anorexia will want their weight to be as low as possible – much less than the average for their age and height. They are so afraid of gaining weight that they cannot eat normally.
After they have eaten, they may try to get rid of food from their body by making themselves sick regularly. Signs of regular vomiting could include:
The need to obsessively burn calories usually draws people with anorexia to ‘high-impact’ activities, such as running, dancing or aerobics. Some people will use any available opportunity to burn calories, such as preferring to stand rather than sit.
They may try to make food pass through their body as quickly as possible. For example, by taking:
In reality, laxatives and diuretics have little effect on the calories absorbed from food.
Although anorexia means ‘loss of appetite’, people with anorexia nervosa do not usually lose their appetite; they like food and feel hungry.
However, they do not think about food in the same way as other people. This can show itself in various ways. For example, they may:
Someone with anorexia nervosa strictly controls what they eat. For example, by:
They may also drink lots of fluids that contain caffeine, such as coffee, tea and low-calorie fizzy drinks, as these can provide a low-calorie, short-term burst of energy.
Some people with anorexia also begin to use illegal stimulant drugs known to cause weight loss, such as cocaine or amphetamines.
People with anorexia often believe that their value as a person is related to their weight and how they look. They think other people will like them more if they are thinner, seeing their weight loss in a positive way.
They often have a distorted view of what they look like (their body image). For example, they think they look fat when they are not. They may try to hide how thin they are by wearing loose or baggy clothes.
Many people will also practise a type of behaviour known as ‘body-checking’, which involves persistently and repeatedly:
Anorexic people usually have low self-esteem or self-confidence. They may withdraw from relationships and become distant from members of their family and friends.
Anorexia can also affect the person’s school work or how well they perform their job.
They may find it difficult to concentrate, and they might lose interest in their usual activities. They may have few interests, even though they seem busier than usual.
Eating too little for a long time can result in physical symptoms, such as:
Their heartbeat may be slow or irregular, which can lead to poor circulation. They may also:
In children with anorexia, puberty and the associated growth spurt may be delayed. They may gain less weight than expected (if any) and may be smaller than other people of the same age.
Women and older girls with anorexia may stop having their periods (known as amenorrhoea or absent periods). Anorexia can also lead to infertility.
There is no single cause for anorexia. Most experts have argued that the condition is caused by a combination of psychological, environmental and biological factors, which lead to a destructive cycle of behaviour.
A widely accepted model based on these factors is that some people have distinct personality traits that make them more vulnerable to anorexia.
Environmental factors, such as going through puberty or living in a culture where thinness is an ideal, then causes the person to begin a pattern of long-term dieting and weight loss.
The lack of a normal diet has a biological effect on the brain, which helps reinforce the obsessive thinking and behaviour associated with anorexia.
A cycle then begins. The more the person diets, the greater its effect on the brain and the greater the desire to lose weight. This means that symptoms gradually, and then rapidly, get worse.
Each of these factors is explained in more detail below.
Research has found that most people who develop anorexia share certain psychological factors that help to define their personality and, to some extent, their behaviour. These include:
The fact that most cases of anorexia develop during puberty suggests that puberty itself is an important environmental factor contributing to anorexia.
It may be that the combination of the hormonal changes during puberty and feelings of stress, anxiety and low self-esteem that many teenagers have during puberty could trigger anorexia.
Another important environmental factor is Western culture and society. Girls (and, to a lesser extent, boys) are exposed to a wide range of different media which constantly reinforce the message that being thin is the only way to be beautiful, and that thinness should be pursued at all costs.
At the same time, magazines and newspapers focus on celebrities’ minor physical imperfections, such as gaining a few pounds or having cellulite.
Other environmental factors that may contribute towards anorexia include:
Your brain requires a healthy, nutritious diet to function normally. It uses a fifth of all the calories you eat. So the extreme dieting associated with anorexia can disrupt the normal functions of the brain, possibly making anorexia symptoms worse.
Malnutrition can also change the balance of hormones in the body, which can disrupt the normal functioning of the brain.
There are a number of theories on how the brain may be affected by anorexia. One theory is that the changes mentioned above cause the brain to become very sensitive to the effects of an amino acid called tryptophan, found in almost all types of food.
This sensitivity may then cause feelings of anxiety in people with anorexia when they eat. At the same time, starving themselves and excessive exercise is known to lower levels of tryptophan, which may make the person feel calmer and more relaxed.
Another theory is that the system controlling a person’s sense of appetite becomes disrupted.
Appetite is controlled by a part of the brain called the hypothalamus. When your body needs more food, your hypothalamus releases chemicals, known as neurotransmitters and neuropeptides, which stimulate your appetite.
Once you have eaten enough food, your body will release a hormone called leptin, which signals to your hypothalamus that you have eaten enough food. Your hypothalamus will release a different set of chemicals that essentially reward you for eating, and make you feel satisfied.
It is thought that due to changes in the brain, the ‘appetite-reward pathway’ becomes scrambled in people with anorexia. The feeling of fullness after a meal does not produce a sense of reward, but a sense of anxiety, guilt or self-loathing. In turn, feeling hungry may help to reduce these negative feelings.
People with anorexia nervosa often do not seek help, probably because they are afraid. Many hide their condition for a long time, sometimes years.
They usually find it difficult to admit there is a problem, or even talk about their symptoms. They will probably disagree that they need to gain weight, and they may not even realise that anything is wrong.
If someone has anorexia, the most important step towards diagnosis and treatment is for them to:
However, to take this first step they may need lots of support and encouragement.
If you have eating problems or think you may have anorexia, it is important to seek help as soon as possible. You could start by:
If someone close to you is showing signs of anorexia, you may want to offer help and support.
You could try talking to the person about how they feel and encourage them to think about getting help. But try not to put pressure on them and be critical of them, as this could make things worse.
You may want to seek advice on how best you can help. For example, a healthcare professional such as your own GP or a support group can provide information on:
You could also offer to help by going with the person to see their GP. See Anorexia nervosa – treatment for more information.
When making a diagnosis, your GP will probably ask questions about your weight and eating habits. For example, they may ask:
It is important to answer these questions honestly. Your GP is not trying to judge you or ‘catch you out’. They just need to accurately assess how serious your symptoms are.
Your GP may not need to carry out any tests to diagnose anorexia nervosa, but they will probably check your pulse and blood pressure.
If you have anorexia, you have a higher risk of developing some heart conditions, such as irregular heartbeat (arrhythmia). Sometimes an ECG (electrocardiogram) may be needed to check how well your heart is working.
Your GP may do blood tests to check the level of:
However, blood tests can sometimes give normal results in an anorexic person who is very thin and has a very low body weight.
If your GP thinks you may have anorexia, they may refer you to a specialist in eating disorders for a more detailed assessment – see Anorexia – treatment for more information. Your GP sometimes carries out this assessment.
Before your treatment begins, you will probably have an overall assessment of your health. This may be done by your GP or another healthcare professional, such as one that specialises in eating disorders.
The assessment will help your healthcare professional draw up a plan for your treatment and care. For example, they may assess:
If you are diagnosed with anorexia nervosa, your GP will probably be involved in your ongoing treatment and care. Other healthcare professionals may also be involved in your treatment, such as:
If a child or teenager has anorexia, a paediatrician (doctor who specialises in children) may also be involved in their treatment.
Where you are treated may depend on how mild or severe your condition is. For example, you may be treated:
In some parts of England, eating disorders such as anorexia are treated by community mental health teams, which are made up of different health and social care professionals. See ‘Mental health services – professionals’ for more information on community mental health teams.
In other areas, there are units that specialise in treating eating disorders. Some services that treat eating disorders also specialise in treating young people.
It is important to start treatment as early as possible, especially if someone has already lost a lot of weight.
Treatment for anorexia usually includes:
These treatments work better when combined, rather than on their own.
Your physical health will be monitored closely during your treatment. For example:
In children and young people with anorexia, their growth, development and weight will be monitored closely. Their height will also be checked regularly against the average for their age and sex.
Other health problems caused by your anorexia will also be treated. For example:
Your healthcare professional will give you advice on how to increase the amount you eat so you can gain weight safely.
They will probably ask about your current eating habits and how much fluid you drink, as well as lifestyle issues, such as smoking and alcohol. This will determine what advice they give you, and help them to identify any deficiencies in your diet, such as a lack of vitamins.
Your healthcare professional will help you to develop healthy eating habits, such as:
You may need to start by eating small amounts of food, then gradually increase what you eat. Your body will not be used to dealing with normal amounts.
You may need to take supplements, such as multivitamins or multiminerals, to adjust the chemical balance in your body. Some experts think that this should be done before you start gaining weight.
Work towards having a regular pattern of eating, with three meals a day. A target weight may be set, so you can aim for a minimum healthy weight.
If you are treated as an outpatient, aim to gain an average of 0.5kg a week. Most people can achieve this by eating around 3,500 to 7,000 extra calories each week. This level of weight gain helps to avoid complications that can occur if you gain weight more quickly, such as a chemical imbalance in your body.
If your weight loss is severe, treatment in hospital may be needed to help you start to gain weight. This is sometimes called ‘refeeding’. Your health will be closely monitored, particularly in the first few days. People treated as inpatients should aim to gain an average of around 0.5–1.0kg (1-2lbs) a week.
Various types of psychological treatment can be used to treat anorexia, such as:
These different types of psychological treatments are discussed below.
CAT is based on the theory that serious mental health conditions such as anorexia are caused by unhealthy patterns of behaviour and thinking, which a person has developed in their past, usually in their childhood.
CAT involves a three-stage process that you will work through with your therapist:
CBT is based on the theory that how we think about a situation affects how we act. In turn, our actions can affect how we think and feel. It is therefore necessary to change the act of thinking (cognition) and our behaviour at the same time.
The therapist will show you how the symptoms of anorexia are often associated with unhealthy and unrealistic thoughts and beliefs regarding food and diet. For example, thinking that:
The therapist will encourage you to adopt healthier, more realistic ways of thinking that should lead to more positive behaviour.
For more information, see the Health A-Z topic on cognitive behavioural therapy.
IPT is based on the theory that our relationships with other people and the outside world in general have a powerful effect on our mental health.
Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt that are caused by problems with interacting with people.
During IPT, the therapist will explore any negative issues associated with your interpersonal relationships and how these issues can be resolved.
FPT is based on the theory that mental health conditions may be associated with unresolved conflicts that occurred in the past, usually in childhood, that are being re-acted in adult life.
FPT encourages you to think about how early childhood experiences may have affected you. You may then be able to find more successful ways of coping with stressful situations and negative thoughts and emotions.
Anorexia does not just impact on one individual; it can have a big impact on the person’s family.
Family therapy involves the person with anorexia and close members of their family discussing how anorexia has affected the family, and the positive changes the person and their family can make.
With the exception of family therapy, there is little scientific evidence to show that the treatments listed above are effective in treating anorexia.
This is not to say they are ineffective; just that very little research has been done to investigate their effectiveness in anorexia.
Little research has been done in this area because many people with anorexia are in denial about their condition, so are unlikely to take part in medical trials. Also, many medical trials that were done had to be abandoned because many of the participants dropped out.
The type of treatment you choose may be based on personal preference and what services are available in your local area. Some people find using a combination of different treatments useful, such as family therapy and CBT.
Research studies have shown that medication alone is not usually effective in reducing anorexia symptoms.
Medication is usually only recommended to treat any associated symptoms, such as obsessive compulsive disorder (OCD) or depression.
Any medication that is prescribed for you, such as antidepressants, will be recommended in combination with one of the psychological or nutritional treatments described above.
Research has found that a medication called olanzapine may be useful in treating anorexia in people who do not respond to other treatments. Olanzapine was originally designed to treat psychosis (where you are unable to distinguish between reality and imagination), and some researchers have argued that it may also be helpful in reducing a person’s anxiety around issues such as weight and diet.
Side effects of olanzapine include:
Occasionally, someone with anorexia may refuse treatment even though they are severely ill and their life is at risk.
In such a situation, doctors may decide to admit the person to hospital for compulsory treatment under the Mental Health Act. This is sometimes called ‘sectioning’ or being ‘sectioned’.
If anorexia nervosa is not treated, the condition can lead to severe health problems.
If treatment is not improving your symptoms, or you start to get worse, your healthcare professional may consider changing your treatment. This may include treatment in hospital if your health is seriously at risk.
It is quite common for anorexia to return after treatment. For example:
If someone has anorexia for a long time, it can lead to severe complications and health problems that can sometimes be permanent, such as damaged bones.
People with anorexia have an increased risk of:
Sometimes, anorexia can lead to another eating disorder called bulimia nervosa, where the person binge eats, then immediately makes themselves sick or uses laxatives to rid their body of the food.
Anorexia can cause an imbalance of minerals in the blood, such as potassium, calcium and sodium. These minerals play an important part in keeping you healthy. For example, a common complication is a low level of potassium (hypokalaemia), which can cause:
Low levels of calcium can cause muscles to contract tightly and painfully (spasms). Lack of calcium and vitamin D can cause bone damage.
Lack of sodium (hyponatraemia) can cause people to become confused. In severe cases, it can cause fits (when your body jerks uncontrollably because of your muscles contracting).
Other complications of anorexia can include:
Misuse of laxatives can permanently damage the bowels and cause permanent constipation.
If you have anorexia and are pregnant, your GP or midwife will monitor your health closely during your pregnancy and after your baby is born. You may need extra health checks as part of your antenatal and postnatal care.
Anorexia during pregnancy can increase the risk of complications, such as
You are also likely to need extra care and support during pregnancy if you have previously had anorexia and recovered from it.
If you have anorexia and another health condition, you will need to take extra care of your health. For example:
The term ‘eating disorder’ covers conditions such as anorexia nervosa, bulimia nervosa and binge eating.
These disorders generally develop over time, sometimes over years, and often at a point when life brings fear and insecurity.
The National Institute for Clinical Excellence (NICE) has issued guidance to the NHS on eating disorders. Although chiefly intended for people with eating disorders, the information may also be helpful for family members and those who care for people with eating disorders.
The guidelines aim to improve the care and treatment provided in the health service and look at different areas of diagnosis, treatment, care and self-help.
The NICE guidelines contain information on the following topics: