What Is Bulimia Nervosa?

Bulimia nervosa is an eating disorder that involves a pattern of frequent binge eating and then purging to avoid gaining weight. Binge eating is when a person consumes an unusually large amount of food in a short period of time, often feeling out of control or unable to stop while doing so. They will then purge, which is usually done by throwing up, but can also include misuse of laxatives, diuretics, or extreme exercise.  

Bulimia nervosa generally starts in adolescence, and in this age group it’s actually thought to be more common — by one estimate more than twice as common — than anorexia nervosa. And like anorexia, it’s treated most effectively with family-based treatment (FBT).

But bulimia is harder to spot than anorexia. Kids with bulimia usually are not underweight and they may appear to eat a healthy amount at family meals. Bingeing and purging are most often done in secret. When kids go into treatment, many parents are shocked to find out how often they’ve been vomiting after meals, notes Daniel Le Grange, PhD, director of the Eating Disorders Program at the University of California, San Francisco.

Despite its prevalence, far fewer teenagers get treatment for bulimia than anorexia. That may be because bulimia is easier to hide from parents, Dr. Le Grange explains, and because kids are often embarrassed to admit that they have it.

But bulimia is just as life-threatening as anorexia, though the causes of death are perhaps different in the two disorders.

The key symptoms of bulimia are recurring episodes of binge eating, followed by purging, at least once a week for no less than three months at a time. As is the case in anorexia, young people with bulimia also have an intense focus on body weight as the basis for self-esteem.

Binge eating is defined as eating an amount of food that’s larger than what most individuals would eat in a similar period of time under similar circumstances. Dr. Le Grange notes that what’s considered an unusually large amount is relative to the person’s culture. The eating episode is accompanied by a feeling of loss of control over eating. It’s common for teens with bulimia to binge on calorie-rich foods they would otherwise avoid and consume only low-calorie foods between episodes.

Purging involves the use of compensatory behaviors to prevent weight gain, such as self-induced vomiting, fasting, excessive exercise, or the misuse of laxatives or diuretics.

Accompanying the bingeing and purging is an intense focus on weight and body shape as the basis for the teenager’s self-esteem. Like those with anorexia, kids with bulimia are obsessed with their appearance and very worried about gaining weight. Bulimia is 10 times more prevalent in girls than it is in boys.

While kids often hide symptoms of this disorder, there are behaviors that can be signs of bulimia that parents might notice, especially if they occur frequently. These behaviors include:

• Worrying or complaining about being fat
• Having a distorted, negative body image
• Eating large quantities of food in one sitting, including foods they usually avoid
• Strict dieting or fasting
• Being secretive about eating
• Going to the bathroom right after eating
• Disappearance of large amounts of food
• Drinking excessive amounts of water or beverages  
• Using excessive amounts of mouthwash, mints, and gum  
• Exercising too much
• Having sores, scars, or calluses on their knuckles or hands
• Having damaged teeth and gums

One important difference between anorexia and bulimia is how kids feel about what they are doing to avoid weight. Anorexia is what Dr. Le Grange calls “ego syntonic,” meaning that it is aligned with the person’s values and self-image. As a result, kids with anorexia don’t think there’s anything wrong with them, and they often resist treatment.

Bulimia, by contrast, is by and large “ego dystonic,” meaning that behaviors such as bingeing and purging conflict with the person’s values and sense of self. “Most young people with bulimia nervosa,” Dr. Le Grange notes, “do not like the fact that they have bingeing episodes and then compensatory behaviors like self-induced vomiting that are unpleasant ways of getting rid of excess calories. Such episodes are often followed by guilt, disgust, and/or self-loathing.”

While kids with anorexia may be proud of their ability to resist eating and even be admired by other kids, those who binge and purge often see it as a sign of weakness and feel ashamed of these behaviors. It’s common for kids in treatment for bulimia to say they started out meeting criteria for anorexia and then resorted to binge eating because they found restricting calories too difficult. Some of these young people, Dr. Le Grange adds, even describe themselves as “having failed at anorexia.”

Due to the many dangerous health risks associated with this disorder, bulimia is associated with an increased likelihood of an early death. Unfortunately, these medical risks are often underestimated because they’re not visible, and at least half of the young people with the disorder are at a healthy-looking weight.

But frequent purging, whether by vomiting, laxatives, or enemas, can damage multiple organs in the body and cause electrolyte imbalances and other health risks. This can lead to irregular heartbeats and possibly heart failure, which is one of the main causes of death in people with bulimia. Repeated vomiting can cause a sore throat and chest pain from esophagus burns, and in some instances even esophageal tears. It can also lead to tooth decay, gum disease, and damage to the salivary glands. A weakened gut lining can make it hard for the body to absorb nutrients, causing one’s bones to become brittle and weak, resulting in higher risk for osteoporosis. Digestive disruption can cause stomach pressure and nausea. Abuse of laxatives can irritate the bowels and lead to constipation and diarrhea. Additionally, dehydration from purging can result in kidney stones and infections.

To prevent or reduce long-term damage from this disorder, it’s important to seek treatment as soon as possible.

Family-based treatment (FBT) has been shown in studies to be the most effective treatment for adolescents with bulimia, and is recommended by the American Psychiatric Association. In the case of bulimia, the main goal is usually not gaining weight but helping the patient eliminate the bingeing and purging episodes and maintain healthy eating habits.

The parents’ role is to supervise the child carefully enough to inhibit bingeing and purging behaviors. That might mean, for instance, sitting with the child after meals to prevent purging, monitoring trips to the bathroom, and being the one to flush the toilet.

“These are all very intrusive steps,” Dr. Le Grange admits. “But without that level of vigilance, there’s no way you’re going to get a handle on the behaviors. So, we say to the parents, ‘This is what would happen if Amanda was in an inpatient unit. Do you think that you could adopt some of those levels of supervision? This may be what’s necessary to help her overcome these urges and these behaviors that are not just unpleasant, but life-threatening.’ And so parents will usually agree.”

Parents also support their child by what experts call “externalizing the disorder”— identifying the bulimia as separate from the child. “Young people do not choose to develop these illnesses, and illness-related behaviors are not willfully engaged in, even if it seems so at times,” notes Dr. Le Grange.

To avoid being critical or angry, parents are encouraged to keep in mind that the child is in the grip of a powerful disorder that is influencing their thoughts, feelings, and behaviors. They are coached on how best to support their child through this ordeal. “The parents’ task is to battle the bulimia,“ notes Dr. Le Grange, “not their healthy child, who is still there but may be overshadowed by the disorder.”

One challenge in FBT for bulimia is that progress is more difficult to track than with anorexia, because it depends on reports from the patient regarding binge eating and purging episodes, corroborated by their parents, rather than a scale that reports weight gain. The therapist depends on the patient accurately reporting the weekly count of binging and purging.

Sometimes the young person feels so embarrassed that they won’t acknowledge the true extent of their binging and purging. “When that happens, the clinician needs to help parents share the real frequency of these behaviors without being critical,” notes Dr. Le Grange. “They need language that they can use to express sympathy that the illness has gotten the hold of the young person in this way, rather than saying, ‘Oh, no, that is just blatantly untrue. She vomited at least six times,’ and you can just hear the criticism rolling from the parents’ tongue.”

What works in the favor of FBT for bulimia is that kids with the disorder tend to be less resistant to participation in treatment than those with anorexia. In part, Dr. Le Grange says, that’s because kids may actually want help to stop these behaviors that they find embarrassing and distressing. This can give parents some leverage in the treatment process, and the child can help articulate how they think parents can best support their changing these behaviors.

But Dr. Le Grange also notes that, for the most part, kids with bulimia tend not to be as emotionally impacted as those with anorexia. For instance, “You don’t typically see someone with bulimia nervosa declining time with their friends or not wanting to go out anymore, isolating themselves. They would still find a way to really be out there in the world with their friends.”

“At least eighty plus percent of young people with bulimia can and should be treated as outpatients,” notes Dr. Le Grange. “If they really have to be admitted to a hospital, then it’s because the degree of engagement in binging and purging is such that parental effort has not made any impact on these behaviors.”