Bulimia nervosa

Any person, at any stage of their life, can experience an eating disorder. More than one million Australians are currently living with an eating disorder (1).

Of people with eating disorders, 12% have bulimia nervosa compared to 3% with anorexia nervosa, 47% with binge eating disorder and 38% with other eating disorders (1). Of people with bulimia nervosa, 70% are female (2).

Eating disorders are not a choice but are serious mental illnesses. Eating disorders can have significant impacts on all aspects of a
person’s life – physical, emotional and social. The earlier an eating disorder is identified, and a person can access treatment, the greater the opportunity for recovery or improved quality of life.

_{Figure 1. Prevalence of eating disorders by diagnosis}

What is bulimia nervosa?

Bulimia nervosa frequently begins during or after a period of dieting. A person with bulimia nervosa will experience a sense of lack of control and will eat a large amount of food within a relatively short period of time. The person will often feel guilt and shame during or after the episode and will engage in compensatory behaviours with the intention to prevent weight gain.

Bulimia nervosa is a serious, potentially life-threatening mental illness. Bulimia nervosa is characterised by recurrent episodes of binge eating, followed by compensatory behaviours, such as vomiting or excessive exercise to prevent weight gain. 

A person with bulimia nervosa can become stuck in a cycle of eating in an out-of-control manner, followed by attempts to compensate for this, which can lead to feelings of shame, guilt and disgust. These behaviours can become more compulsive and uncontrollable over time, and lead to an obsession with food, thoughts about eating (or not eating), weight loss, dieting and body image.

These behaviours are often concealed and people with bulimia nervosa may attempt to keep their eating and exercise habits secret. As a result, bulimia nervosa may go undetected for a long period of time.

Characteristics of bulimia nervosa

Binge eating

Binge eating involves two key features:

• Eating a very large amount of food within a relatively short period of time (e.g., within two hours)
• Feeling a sense of lack of control over eating (e.g., feeling unable to stop yourself from eating)

Compensatory behaviours

Compensatory behaviours are used as a way of trying to prevent weight gain after binge eating episodes. They include:

• Vomiting
• Misusing laxatives or diuretics
• Fasting
• Excessive exercise
• Use of any drugs, illicit, prescription and/or ‘over the counter’, inappropriately for weight control

Self-evaluation
A person with bulimia nervosa places an excessive emphasis on body shape or weight in their self-evaluation. This can lead to the person’s sense of self-esteem and self-worth being largely defined by the way they look.

Risk factors

The elements that contribute to the development of bulimia nervosa are complex, and involve a range of biological, psychological, and sociocultural factors. Any person, at any stage of their life, is at risk of developing an eating disorder. An eating disorder is a mental illness, not a choice that someone has made.

Warning signs

The warning signs of bulimia nervosa can be physical, psychological, and behavioural. It is possible for a person with bulimia nervosa to display a combination of these symptoms, or no obvious symptoms.

Physical

• Signs of damage due to vomiting including swelling around the cheeks or jaw, calluses on knuckles, damage to teeth and bad breath
• Feeling bloated, constipated or developing intolerances to food
• Loss of or disturbance to menstruation
• Fainting or dizziness
• Fatigue or lethargy
• Sleep disturbances
• Compromised immune system (e.g., getting sick more often)
• Sudden weight loss, gain or fluctuation

Psychological

• Preoccupation with eating, food, body shape and weight
• Intense fear of gaining weight
• Preoccupation with food or activities relating to food
• Heightened anxiety or irritability around mealtimes
• Heightened sensitivity to comments or criticism (real or perceived) about body shape or weight, eating or exercise habits
• Low self-esteem and feelings of shame, self-loathing or guilt
• Body dissatisfaction and negative body image
• Depression, anxiety, self-harm or suicidality
• Obsession with food and need for control

 Behavioural

• Repetitive dieting behaviour such as counting calories, skipping meals, fasting or avoidance of certain foods or food groups
• Evidence of binge eating such as disappearance or hoarding of food
• Evidence of vomiting or misuse of laxatives, appetite suppressants, enemas and/or diuretics
• Frequent trips to the bathroom during or shortly after meals
• Patterns or obsessive rituals around food, food preparation and eating
• Avoidance of, or change in behaviour in social situations involving food
• Social withdrawal or isolation from friends and family
• Secretive behaviour around eating
• Compulsive or excessive exercising
• Substance misuse
• Inappropriate hydration behaviours

It is never advised to ‘watch and wait’. If you or someone you know may be experiencing an eating disorder, accessing support and treatment is important. Early intervention is key to improved health and quality of life outcomes.

Impacts and complications

A person with bulimia nervosa may experience serious medical and psychological consequences (3, 4).

Medical

Some of the medical impacts and complications associated with bulimia nervosa include:
• Chronic sore throat, indigestion, heartburn and reflux
• Inflammation and rupture of the oesophagus and stomach from frequent vomiting
• Stomach and intestinal ulcers
• Chronic irregular bowel movements, constipation and/or diarrhoea due to deliberate misuse of laxatives
• Heart problems including slow heart rate, irregular heartbeat and low blood pressure
• Electrolyte disturbance, including potassium and sodium
• Osteoporosis or osteopenia: a reduction in bone density caused by a specific nutritional deficiency
• Fatigue and lethargy
• Loss of or disturbance to menstruation
• Increased risk of infertility
• Death

Psychological

Some of the psychological impacts and complications associated with bulimia nervosa include:
• Extreme body dissatisfaction/distorted body image
• Obsessive thoughts and preoccupation with eating, food, body shape and weight
• Social withdrawal
• Feelings of shame, guilt, and self-loathing
• Depressive or anxious symptoms and behaviours
• Self-harm or suicidality
• Substance misuse

Recovery

It is possible to recover from bulimia nervosa, even if a person has been living with the illness for many years. The path to recovery can be long and challenging, however, with the right team and support, recovery is possible. Some people may find that recovery brings new understanding, insights and skills.

Treatment options

Access to evidence-based treatment has been shown to reduce the severity, duration and impact of bulimia nervosa.

Evidence-based psychological therapies to consider for the treatment of bulimia nervosa in children and adolescents include:
• Eating disorder-focused CBT (CBT-ED) with family involvement
• Bulimia nervosa-focused family therapy (5)

Evidence-based psychological therapies to consider for the treatment of bulimia nervosa in adults include:
• Guided self-help CBT-ED
• CBT-ED
• Interpersonal psychotherapy (IPT) (5)

Most people can recover from an eating disorder with community-based treatment. In the community, the minimum treatment team includes a medical practitioner such as a GP and a mental health professional.

Inpatient treatment may be required when a person needs medical and/or psychiatric stabilisation, nutritional rehabilitation and/or more intensive treatment and support.

Getting help

If you suspect that you or someone you know may have bulimia nervosa, it is important to seek help immediately. The earlier you seek help the closer you are to recovery. Your GP is a good ‘first base’ to seek support and access eating disorder treatment.

To find help in your local area go to NEDC Support and Services.

Download the bulimia nervosa fact sheet here.

References

1. Deloitte Access Economics. Paying the price: the economic and social impact of eating disorders in Australia. Australia: Deloitte Access Economics; 2012.
2. Hay P, Girosi F, Mond J. Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population. J Eat Disord. 2015;3(1):1-7.
3. Gibson D, Workman C, Mehler PS. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019;42(2):263-74.
4. Allen KL, Byrne SM, Oddy WH, Crosby RD. DSM–IV–TR and DSM-5 eating disorders in adolescents: prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents. J Abnorm Psychol. 2013;122:720-32.
5. Heruc G, Hurst K, Casey A, Fleming K, Freeman J, Fursland A, et al. ANZAED eating disorder treatment principles and general clinical practice and training standards. J Eat Disord. 2020;8(1):63.