Bulimia

What is bulimia?

If you suffer from bulimia, you might not feel in control of your eating, like finding it difficult to stop or limit how much you eat in a given period of time (‘binge-eating’). These episodes are usually followed by things you do to avoid gaining weight, such as vomiting, using laxatives, restricting how much food you eat, or exercising excessively. This can have a very negative impact on your life, and you might worry a lot about your body shape or weight.

What is it like to have bulimia?

Zahara struggled with bulimia. Her story shows what it’s like to be affected in this way.

Zahara’s difficult relationship with food and her body

My family commented on my appearance since I was little, so I’ve always felt conscious about the way I look. I first started dieting when I was about thirteen – I felt so much bigger and less attractive than my friends. Even after I lost a bit of weight, I still didn’t like how my body looked. Following so many beautiful, thin women on social media probably didn’t help either.

Things got a lot worse when I was about eighteen and doing my exams. I broke up with my boyfriend just before I sat them and didn’t get the results I wanted. I felt like such a failure. I cut out more foods from my diet. I was constantly hungry and could barely function. It was hard to keep up and I soon started binge-eating. This was terrifying: I thought that if I didn’t do something about it, my weight would go up and up, so I started vomiting too – after binges at first, and later whenever I had a big meal.

It’s been a long time since then and I’m still living with bulimia. Sometimes I’m able to stick to my diet without losing control, but then I go through bad phases where I binge and purge all day. Either way, it feels like food rules my life. My dentist said I’ve lost a lot of the enamel on my teeth, which worries me.

I’m desperate to stop binge-eating, but it feels like it’s something I can’t control. My husband says that I don’t eat enough and that I exercise too much, but I’m terrified about what will happen to my weight if I eat like he does. I’ve lived with bulimia for so long that it feels like I’ve forgotten what ‘normal’ eating is.

Do I have bulimia?

Bulimia should only be diagnosed by a mental health professional or a doctor. However, answering the screening questions below can give you an idea of whether you might find it helpful to have a professional assessment.

Are there times when you feel like you’ve lost control over how much you eat?	Yes	No
Do you ever vomit because you feel full or anxious about gaining weight?	Yes	No
Do you sometimes restrict how much you eat?	Yes	No
Do you ever take laxatives, diet pills, or diuretics in order to control your weight?	Yes	No
Do you follow strict rules related to food (e.g., about what you can eat or the number of calories you can consume)?	Yes	No
Do you sometimes feel anxious or guilty after eating?	Yes	No
Do you feel unhappy about your weight or body shape?	Yes	No
Do you want to lose weight, or do you worry about your weight going up?	Yes	No
Do you feel uncomfortable with other people seeing your body?	Yes	No
Do you often find yourself thinking about your eating, shape, or weight?	Yes	No
Does your eating, shape, or weight have a negative impact on how you see yourself as a person, or stop you from doing things?	Yes	No

If you answered ‘yes’ to most of these questions, you may be suffering from bulimia. You might find it helpful to speak to your family doctor or a mental health professional about how you are feeling.

All types of eating disorders are serious, so don’t hesitate to seek support even if you aren’t sure if this applies to you: if you have any concerns about your eating, it’s important to let someone know.

What causes bulimia?

There is no single cause for bulimia. Some things that make you more likely to experience bulimia include ^{[2, 3]}:

• Cultural influences. Women are at greatest risk of developing bulimia, particularly those who live in Western cultures. These cultures place a lot of value on thinness, which can contribute to the development of disordered eating. However, men and people living in other cultures can also experience bulimia.
• Traumatic experiences. People who have experienced traumatic events such as bullying related to their appearance, or childhood abuse, have a higher risk of developing bulimia. This does not mean that everyone with bulimia has experienced abuse or trauma.
• Self-esteem and emotional factors. Research suggests that individuals with bulimia often hold longstanding, negative beliefs about themselves. This often takes the form of low self-esteem. People who find it difficult to express or manage difficult emotions are also at a higher risk of developing an eating disorder like bulimia.

Research suggests that there may be genes that may make you more likely to develop bulimia, but these findings are mixed and complicated. Eating disorders are likely to emerge from a combination of genetic and environmental factors.

What keeps bulimia going?

Research has shown that several treatments that can help with bulimia, and cognitive behavioral therapy (CBT) appears to be one of the most effective ^[4]. CBT therapists work a bit like firefighters: while the fire is burning they’re not so interested in what caused it, but are more focused on what is keeping it going, and what they can do to put it out. This is because if they can work out what keeps a problem going, they can treat the problem by ‘removing the fuel’ and interrupting this maintenance cycle.

Studies suggest that bulimia is often maintained by several different factors. These include:

Treatments for bulimia

Psychological treatments for bulimia

The psychological treatment for adults with bulimia that has the strongest research support is cognitive behavioral therapy (CBT), and is effective in a one-to-one or a self-help format ^{[4, 5]}. One-to-one CBT for bulimia is sometimes called ‘eating-disorder-focused cognitive behavioral therapy’ (CBT-ED), or includes ‘enhanced cognitive behavioral therapy’ (CBT-E) ^{[6, 7]}. Research suggests that group CBT for bulimia can also be helpful ^[8].

CBT-ED is a psychological therapy specifically developed for treating eating disorders such as bulimia. ‘Ingredients’ of effective CBT for bulimia include ^[9,10]:

• Developing a personalized model or ‘formulation’ of your eating disorder.
• Learning more about food, nutrition, weight, the body, and weight control behaviors relevant to you (e.g., why vomiting isn’t effective).
• Monitoring how much you eat throughout the day (e.g., keeping a ‘food diary’).
• Introducing a more regular pattern of eating, or experimenting with new foods.
• Checking your weight during appointments to test your beliefs about eating differently.
• Addressing events and emotions that trigger your eating disorder behaviors.
• Changing behaviors that keep you focused on your shape, weight, and eating (e.g., checking your body, using the mirror, or comparing yourself to others).
• Re-engaging in activities and interests that matter to you, or building a bigger life for yourself.
• Developing a plan to help you maintain and continue your progress after therapy.
• Tackling ‘broader’ factors related to your eating disorder, if needed (low self-esteem, perfectionism, or relationship difficulties).

Medical treatments for bulimia

Medications are sometimes offered to help people suffering from bulimia with their mood or physical health, but they should not be used as the sole treatment.

References

1. van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 34, 515-524.
2. Waller, G., & Sheffield, A. (2008). Causes of bulimic disorders. Psychiatry, 7, 152-155.
3. Goncalves, S., Machado, B. C., Martins, C., Hoek, H. W., & Machado, P. P. (2016). Retrospective correlates for bulimia nervosa: A matched case-control study. European Eating Disorders Review, 24, 197-205.
4. Slade, E., Keeney, E., Mavranezouli, I., Dias, S., Fou, L., Stockton, S., Saxon, L., Waller, G., Turner, H., Serpell, L., Fairburn, C. G., & Kendall, T. (2018). Treatments for bulimia nervosa: A network meta-analysis. Psychological Medicine, 48, 2629-2636.
5. Hay, P. (2013). A systematic review of evidence for psychological treatments in eating disorders. International Journal of Eating Disorders, 46, 462-469.
6. NICE (2017). Eating Disorders: Recognition and Treatment. NICE Clinical Guideline 69. London: National Institute for Health and Care Excellence.
7. Fairburn, C. G., Bailey-Straehler, S., Basden, S., Doll, H. A., Jones, R., Murphy, R., O’Connor, M. E., & Cooper, Z. (2015). A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behavior Research and Therapy, 70, 64-71.
8. Polnay, A., James, V. A. W., Hodges, L., Murray, G. D., Munro, C., & Lawrie, S. M. (2014). Group therapy for people with bulimia nervosa: systematic review and meta-analysis. Psychological Medicine, 44, 2241-2254.
9. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
10. Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge University

About this article

This article was written by Dr Matthew Whalley and Dr Matthew Pugh, both clinical psychologists. It was last reviewed on 2022/05/06.