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Bulimia Nervosa – an FAQ

When people think about eating disorders, bulimia nervosa is one of the first things that springs to mind. It’s a prominent form of disordered behavior that affects millions of people in the United States, and without professional eating disorder treatment, it can hinder a person’s ability to live their happiest, healthiest life. Despite all this, bulimia nervosa isn’t as well-understood by nonprofessionals. When it happens to a loved one, or yourself, it can cause fear and confusion, but with more understanding, anyone can come to understand that bulimia nervosa is treatable.

Bulimia nervosa is defined by the https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t16/ as the following:

  1. Recurrent episodes of binge eating, as characterized by both:

Eating, within any 2 hours, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances.A feeling that one cannot stop eating or control what or how much one is eating.

  1. Recurrent inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.
  2. The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months.
  3. Self-evaluation is unjustifiability influenced by body shape and weight.
  4. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Purging type: During the current episode, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Nonpurging Type: During the current episode, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

That all sounds like a lot to wrangle – and it can be. Even with such a detailed description, there are always more questions that the DSM-V doesn’t answer. For that reason, we’ve outlined some of the most frequently asked questions we get about bulimia nervosa.

What Are the Causes of Bulimia Nervosa?

Mental health disorders aren’t like medical diagnoses. There is rarely a single cause, like a virus causing measles. Instead, bulimia nervosa treatment centers and other professionals generally agree that several factors combine to cause the disorder.

These normally include a genetic component, in that people who have a family history of eating disorders are more likely to develop the disorder. In a similar vein, certain biological factors come into play. Women and girls have a higher rate than boys and men, as do people with depression, anxiety, and other mental health disorders. The last factor is the person’s upbringing and family environment. Families that put undue pressure on their kids about weight and “beauty” are commonly reported by people entering bulimia nervosa treatment programs.

Please note that every case is different; some of these or all of these factors may be absent when someone goes in for treatment. However, in most cases, all these factors are present.

What Are the Effects of Bulimia Nervosa?

Since the desired effect of the disordered behaviors and purging is to prevent weight gain or spur weight loss, people with bulimia nervosa can become severely underweight, but not always (see below). Regardless of the person’s weight, the disorder can result in several health risks related to malnutrition. Common physical complaints related to bulimia nervosa include lethargy, anemia, easy bruising, dizziness and confusion, stoppage of menstruation, hair loss and dry skin, and various organ failures. Because of the frequent exposure to vomit, the individual’s teeth and esophagus may become painful and eroded.

Several co-occurring disorders often come with bulimia nervosa as well. Depression and various anxiety disorders are much more likely to occur in people with bulimia nervosa, and body dysmorphia (distorted body image) is also very common.

Are People With Bulimia Nervosa Always Underweight?

A resounding “no.” Although the purging behaviors are undertaken to prevent weight gain or counteract the calories taken in during a binge eating episode, bulimia nervosa doesn’t normally result in extreme weight loss the way anorexia nervosa does. In protracted cases, weight loss can occur, and a person can have more than one eating disorder.

In most cases, bulimia nervosa doesn’t cause major weight loss, and many people with the disorder are at a “normal” weight or become overweight. This points to a very common misconception; that people with eating disorders are always emaciated and drawn. There are many different body types, and any of them can host an eating disorder. You can’t judge a book by its cover, and you can’t diagnose an eating disorder by a person’s weight.

Do People With Bulimia Nervosa Always Induce Vomiting?

No. Self-induced vomiting is the most common disordered behavior associated with bulimia nervosa, but a significant subset of people with the disorder do not purge this way. Without some form of purging, the person would not have bulimia nervosa, so what methods are taken?

First and foremost is the abuse of certain medicines that cause the metabolism to quicken or the digestive system to go into overdrive. Amphetamines and other “diet pills” are commonly abused, and can lead to addiction. Some people also abuse diuretics and laxatives to purge the food eaten during a binge eating episode. Lastly, excessive exercise is very common among people with bulimia nervosa. In these situations, the person might exercise even when sick or injured, or compulsively push past their limits.

What Other Disorders Happen at the Same Time as Bulimia Nervosa?

As seen in the diagnostic criteria above, bulimia nervosa behaviors that happen only when the person is experiencing anorexia nervosa symptoms don’t fit the criteria. However, people sometimes change or alternate behaviors related to eating disorders. As an example, a person might fast extensively for a period, showing the signs of anorexia nervosa, then return to the binge/purge cycle. Or they may not purge for a period, but continue to binge eat, which would mark the criteria for binge eating disorder.

Bulimia nervosa is also closely linked to other mental health disorders. Clinical depression and a variety of anxiety disorders are much more frequent in people with bulimia nervosa than those without. These anxiety disorders include obsessive-compulsive disorder, general anxiety, and PTSD. Similarly, substance abuse disorder is as much as five times as common in people with an eating disorder than the general population.

Who Does Bulimia Nervosa Affect?

As with other eating disorders, bulimia nervosa affects young women most prominently. The usual first age of onset is during adolescence, from age 16 to 21. However, it’s a common misconception that bulimia nervosa and other eating disorders only affect young women, particularly white, wealthy young women.

This couldn’t be less true. Bulimia nervosa affects people of all genders, races and ethnicities, and socioeconomic backgrounds. In particular, transgender people face a much higher rate of body dysmorphia and related eating disorders than cisgender people do. Additionally, other members of the LGBTQ community are at higher risk for developing bulimia nervosa. It should be noted that it’s quite likely that due to stigma about eating disorders, straight cisgender men may underreport the incidence of bulimia nervosa and other eating disorders.

How Is Bulimia Nervosa Treated?

There are various different methodologies employed by different eating disorder treatment centers and other professionals, but in general, most treatment follows a basic plan. First, if necessary, the client will be assessed to determine their eating disorder’s type and severity. The care team will then design a personalized treatment plan for the client.

Typically, the first few days will be focused on medical stabilization (if needed) and acclimating to the treatment program. Several different types of therapy are usually required to help the clients make the most of their time in treatment. Group therapy sessions are near-universal; most former clients of eating disorder treatment centers identify them as the most helpful part of their experience. Individual talk therapy and evidence-based sessions are also common, including cognitive retraining therapies like Cognitive Behavioral Therapy.

In addition to psychotherapy, mindful movement classes are often introduced, since excessive exercise is so common in people with eating disorders. This might include mindful meditation, tai chi, or yoga sessions, designed to reconnect the client’s body with movement in a gentle, self-aware way.

Lastly, most bulimia nervosa treatment programs include sessions with a team of dieticians and nutritionists. These professionals help with meal planning and restoring nutritional balance. In the long term, they can provide lessons about how to perform their own meal planning for the client to use after they finish the program.

What Are the Signs of Bulimia Nervosa?

The diagnostic criteria provided by the DSM-V above give the psychiatric indications of bulimia nervosa, but there are certain behavioral characteristics you can look for in yourself or a loved one to give you an indication if there’s cause for concern. These include:

  • Trips to the bathroom immediately after meals
  • Poor body image
  • Frequent fad dieting or fasting
  • Discolored teeth
  • Calluses on the knuckles
  • Smells of vomit
  • Lots of laxative, diuretic, or enema packing found in the house, or the garbage
  • Hoarded food or food wrappers
  • Anxiety or discomfort at meals

Where Can I Learn More About Bulimia Nervosa?

There are many more resources available today than ever before. While you can always peruse our blog to learn more about bulimia nervosa and other eating disorders, there are several other organizations dedicated to spreading awareness and knowledge of eating disorders.The National Eating Disorder Association has copious resources for parents and professionals alike. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) provides resources for families trying to help their loved ones, as well.

However, if you or your loved one is in the throes of bulimia nervosa, it’s best to contact an eating disorder professional or eating disorder treatment center as soon as you can. Recovery outcomes tend to be better with early intervention before the disordered behaviors become entrenched. Reach out today, and get started on your path to a full recovery.


Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.