Bulimia nervosa is a life-threatening eating disorder characterized by binge eating followed by purging. Binge eating is an episode of overeating within a short period of time, in which patients feel unable to control themselves during the overeating episode.

Bulimia nervosa consists of two types depending on the way the patient uses to get rid of the consumed food, purging and non-purging. In the purging type of bulimia nervosa, patients tend to use self-induced vomiting or laxatives, whereas in the non-purging type of bulimia nervosa, patients use either fasting or excessive exercising.

A combination of multiple risk factors can increase a person’s susceptibility to bulimia nervosa, including non-modifiable risk factors such as genetics, biology, gender, and age and modifiable risk factors such as poor body image, low self-esteem, stressful life changes, history of trauma or abuse, and media and societal pressure. Following some lifestyle guidelines can reduce the risk from modifiable factors.    

Signs and symptoms related to bulimia nervosa are divided into physical symptoms, binging, and purging. Physical symptoms include the appearance of wounds and scars on the fingertips, stained teeth, and irregularity of weight. Binge eating symptoms include loss of control while eating, eating large amounts of food during a meal, and eating secretly. Purging signs include consumption of laxatives, diuretics, or enemas, excessive exercise after eating and going to the bathroom directly after a meal to induce vomiting.  

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) sets the diagnostic criteria for bulimia nervosa to include recurrent episodes of binge eating, recurrent inappropriate compensatory behaviors like self-induced vomiting and excessive exercise. The binge eating and inappropriate compensatory behaviors have to occur, on average, at least once a week for 3 months. Self-evaluation of patients with bulimia nervosa is influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Alterations in levels of neurotransmitters and neuropeptides in the brain might explain an alteration in eating habits leading to bulimia nervosa. These neurotransmitters and neuropeptides normally regulate hunger, satiety, and food choice.

As a result of purging behaviors, patients with bulimia nervosa suffer from some serious complications such as dental problems, irregular periods, swollen glands, electrolyte imbalance, and heart and bowel problems.

Many methods are commonly used to treat patients with bulimia nervosa. These include psychotherapy, medications, nutrition education and possibly hospitalization. However, patients with bulimia are exposed to relapses after treatment and they may need long-term care.

Definition of Bulimia Nervosa

Subtypes of Bulimia Nervosa

Causes of Bulimia Nervosa

Risk factors for Bulimia Nervosa

Pathophysiology of Bulimia Nervosa

Signs and Symptoms of Bulimia Nervosa

Diagnosis of Bulimia Nervosa

Treatment of Bulimia Nervosa

Complications of bulimia nervosa

Prevention of Bulimia Nervosa

Prognosis of Bulimia Nervosa

Epidemiology of Bulimia Nervosa

Bulimia nervosa is a life-threatening eating disorder characterized by recurrent episodes of binge eating, followed by one or more inappropriate compensatory behaviors such as self-induced vomiting to prevent weight gain.

Binge eating is defined as an episode where the patient eats an amount of food larger than a normal person can eat within a short period of time, as a result of absence of control during the episodes.

Bulimia nervosa is classified into two main subtypes:

• Purging bulimia

Patients with purging type of bulimia nervosa engage behaviors to compensate for their overeating. Behaviors may include self-induced vomiting, or misuse of laxatives, diuretics or enemas after bingeing.

• Non-purging bulimia

Patients with non-purging type of bulimia nervosa do not engage in purging behaviors, but rather they use fasting, strict dieting, or excessive exercise between binging episodes to prevent weight gain and rid themselves of calories.

The exact cause of bulimia nervosa is unknown. There are several major factors that can lead to bulimia nervosa, such as low self-esteem and concerns about weight and body image.

There are many factors that may increase the risk of getting bulimia nervosa. Some of these risk factors are uncontrollable, while others can be controlled. Risk factors include:

Uncontrollable Risk Factors

These risk factors cannot be changed:

• Gender

Females are more likely to have bulimia nervosa than males. 

• Age

People in their teenage or early adulthood years are more likely to have bulimia nervosa.

• Biology

A deficiency in a neurotransmitter called serotonin may increase the risk of developing bulimia nervosa.

• Genetics

Genetics may play a role because individuals who have first-degree relatives with bulimia nervosa are more likely to have the disorder.

Controllable Risk Factors

These risk factors can be modified to lessen the risk of developing bulimia nervosa:

• Poor body image

People who have a poor body image and those who follow strict diet plans are more likely to have bulimia nervosa.

• Low self-esteem

Usually, individuals who suffer from psychological and emotional problems leading to low self-esteem are more likely to get bulimia nervosa. Such emotional problems could result from depression, perfectionism, or a critical home environment.

• Stressful life changes

Changes in life patterns such as separation from a partner, starting a new life event, and puberty put individuals at an increased risk of getting bulimia nervosa.

• History of trauma or abuse

People who have been subjected to violence or abuse in the past are more likely to get bulimia nervosa.

• Media and societal pressure

The media in all its different forms, such as TV and fashion magazines, imposes the ideal body image and its relation with individual success, which in turn puts individuals under great psychological pressure that increases the probability of getting bulimia nervosa.

Evidence suggests that bulimia nervosa may be associated with changes in levels of neurotransmitters and neuropeptides that are responsible for regulating hunger, satiety, and food choice in normal people. Genetic studies reveal that people with bulimia nervosa display alterations in these neurotransmitters, which might explain the changes in eating habits.  

Data in the literature proposes that patients with bulimia nervosa have inappropriate levels of noradrenaline and serotonin. Serotonin decreases a person’s desire to eat, while noradrenaline normally increases that desire.

Bulimia nervosa has physical signs and symptoms, in addition to symptoms that indicate bingeing and purging. Symptoms include:

Physical symptoms

• Wounds or scars on fingertips

Wound or scars may appear on the patient’s fingertips as a result of the repeated use of fingers to induce vomiting.  

• Stained teeth

Constant vomiting exposes the teeth to stomach acids, which may result in permanent staining and damage to the teeth.

• Normal weight

Usually, people with bulimia nervosa have normal body weight or are somewhat overweight.

• Irregularity of weight

The weight of individuals with bulimia nervosa may fluctuate because of the alternating bingeing and purging.

Binge eating symptoms

• Loss of control while eating

The person with bulimia nervosa will continue eating to the point where they feel pain or discomfort.  They are unable to stop before reaching that point.

• Eating secretly

The person with bulimia nervosa is careful to eat in strict privacy and makes sure that they are not seen eating by others.

• Eating large amounts of food

The person with bulimia nervosa tends to eat an abnormal quantity of food during a meal without any increase in weight. Normal people cannot eat the same amount during a meal.

• Overeating and fasting

Patients with bulimia nervosa alternates between overeating and fasting, i.e., they either consume large amounts of food or they do not eat at all.

• Disappearance of food

People living with someone who has bulimia nervosa notice the disappearance of food and the presence of large amounts of food waste in the trash.

Purging symptoms

• Going to the bathroom after meals

People with bulimia nervosa go straight to the bathroom after eating to get rid of the food they eat. They often use sounds like running the water faucet to cover the sound of vomiting.

• Consumption of laxatives, diuretics, or enemas

A patient with bulimia nervosa will likely use laxatives, diuretics, or enemas to get rid of the food they eat and prevent weight gain.

• Vomit smell

Repeated vomiting will likely result in a smell that is constantly emitted from the patient. Patients may attempt to hide the smell perfumes, toothpaste and chewing gum.

• Excessive exercising

The person with bulimia nervosa exercises hard in an attempt to burn all the calories they consumed during a binge eating episode.

A mental health specialist will diagnose bulimia nervosa using the criteria set in the DSM-5:

• Recurrent episodes of binge eating.
• Recurrent inappropriate compensatory behaviors like self-induced vomiting and misuse of laxatives to prevent weight gain.
• Binge eating and inappropriate compensatory behaviors occur at least once every week for a period 3 months.
• The person’s self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur only during episodes of anorexia nervosa.

Treatment for bulimia nervosa involves:

Psychotherapy

Also known as talk therapy or psychological counseling, it includes discussions of bulimia nervosa and related issues between the patient and a mental health provider. Types of psychotherapy used in treating the disorder may include:

• Cognitive behavioral therapy

It is the most popular type of psychological treatment for bulimia. The therapist discusses the feelings and emotions of the patient in detail to identify unhealthy, negative beliefs and behaviors which make them resort to eating too much. Then the therapist tries to provide the patient with new ways of thinking about situations, feelings and food.

• Family-based therapy

The first step in this type of therapy involves educating parents on how to monitor and intervene in their teenager's unhealthy eating behaviors. The second step is teaching parents how to control and deal with their eating behavior problems in a way that would not affect the eating behaviors of their children.

• Interpersonal psychotherapy

This type of therapy helps patients with bulimia nervosa by teaching them how to deal with problems in their close relationships. Furthermore, it teaches them to improve their communication and problem-solving skills.

Medications

Using antidepressants known as selective serotonin reuptake inhibitors (SSRIs) with psychotherapy may help reduce the symptoms of bulimia nervosa. The US Food and Drug Administration approved the use of fluoxetine as a type of SSRI to treat bulimia nervosa. Some dietary supplements such as potassium or iron may be prescribed to compensate for deficiencies that occur as a result of bulimia nervosa.

Nutrition education and healthy weight

Health care professions can help patients with bulimia achieve a healthy body weight, maintain normal eating habits and ensure proper nutrition by providing them with a comprehensive diet plan.

Hospitalization

Usually, patients with bulimia nervosa are treated outside the hospital, but they may be admitted to the hospital if their health status is poor and they suffer from serious complications.  

In addition to the signs and symptoms that appear on bulimia nervosa patients, it is possible to suffer from some serious complications associated with purging behaviors, such as: 

• Serious dental caries, decalcification of teeth, enamel loss, severe tooth decay, and gum disease.
• Swollen glands, such as swollen salivary glands in the neck and jaw area.
• Constipation and chronic irregular bowel movements.
• Dehydration, electrolyte and chemical imbalances.
• Problems in the entire digestive system.
• Problems in major organ functions, such as the heart.
• Chronic inflammation of the throat.
• Esophageal inflammation and the presence of ruptures in the esophageal structure.
• The stomach may rupture.
• Edema (swelling).
• Inflammation of the pancreas and peptic ulcers.
• Acid reflux disorder.
• Infertility, increased rates of miscarriage, fetal complications and other reproductive complications.
• Absent or irregular menstrual cycles.
• Anxiety and depression.
• Misuse of alcohol or drugs.
• Suicidal tendencies.

There is no direct way to prevent bulimia nervosa. Modifiable factors that may increase the risk of bulimia can be reduced by following some lifestyle guidelines that include:

• Teaching individuals about bulimia nervosa and increase their awareness about bulimia associated risk factors.
• When risk factors are recognized, early intervention should be performed to prevent the disorder from developing.
• Educating individuals about how to have a positive self-image of their body, and build their self-esteem.
• Proper counseling should be provided to individuals who suffer from constant conflict and stress in their lives.  
• Finding balance between school, work, social life, rest, and exercise is one way for individuals to maintain good mental health that protects against bulimia nervosa.
• Individuals who are at risk should be encouraged to develop close relationships with trusted people.
• People, especially the young, should be taught about maintaining healthy eating habits.

The probability of relapse after treatment in patients with bulimia is very frequent. These patients may need long-term care. Usually, bulimia nervosa is a long-term disease where patients need to continuously check their weight, exercise routines, and mental and physical health.

According to an article published in the journal Biological Psychiatry, the estimated lifetime prevalence of bulimia nervosa is 1.5% in women and 0.5% in men.

An article published in US journal The International Journal of Eating Disorders said that people of the middle and upper classes who live in industrialized nations in the West are more susceptible to get bulimia nervosa, with prevalence increasing among adolescents in the last few decades.