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Bulimia Nervosa

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Most people enjoy food – the taste of it, the enjoyment of eating and the anticipation before a nice meal. And virtually everyone in a Western country has had the experience of sitting back after a meal with that uncomfortable feeling in the pit of the stomach that suggests you should have turned down that last sausage roll.

However, some people find that they gain an emotional release from episodes where they may eat too much and for too long. If these urges to binge eat come to control an individual's life, then they may have a form of eating disorder known as bulimia nervosa1.

Signs of the Disorder

The cardinal sign of bulimia is episodes of binge-eating. These can occur up to several times a week, and consist of eating abnormally large amounts of food at a single sitting – a severe binge only stops when the individual gets abdominal pain, is interrupted by somebody else or when vomiting occurs (although many bulimic individuals describe frequent, less severe, binges). Bulimic individuals often describe a loss of control over their eating at these times, and feel that they can't stop the binge once it has started.

When the binge is over, bulimic individuals usually feel ashamed and guilty. They will do their best to hide their binges and purges from others. After a binge, their eating becomes more restrained (and irregular), and they feel the need to compensate for their binge. This can take the form of fasting, increased exercise or amphetamine use, or the individual can purge their meal.

Purging can happen in a number of ways. The most common way is to induce vomiting, but other measures can be used such as diuretics2, laxatives or enemas3. Recurrent vomiting brings its own problems – bulimic individuals may find that their teeth are worn away and that they suffer from mouth ulcers due to exposure to stomach acid. Their fingers can be scarred, the salivary glands in their cheeks may become inflamed, their gullets may get small tears and their body's supply of useful chemicals (such as potassium and chloride) can be depleted. These effects can lead to other, more serious medical problems if the vomiting is not stopped.

Bulimia compared to Anorexia

Bulimia is similar to anorexia nervosa in many ways, and indeed the line is very blurred at times. In both disorders the driving force is an abnormal sense of body image – a bulimic individual worries a lot about their weight and this is tied to their sense of worth, with non-physical qualities like intelligence and personality often being seen as less important than their body shape.

The difficulty in distinguishing betweenthe two varieties of eating disorder doesn't stop there. While anorexic individuals most commonly deal with concerns about their body image by restricting their food intake, many will go through cycles of bingeing and purging. Conversely, bulimic individuals go through periods of fasting typical of anorexia, although they seldom do this consistently enough to reduce their weight significantly (and if they do, by definition they have anorexia, not bulimia).

So what's the difference? Some suggest that there isn't one – that the two disorders are caused by much the same things and the symptoms are merely two extremes on a continuum. However, 90% of purely bulimic individuals (those who classically binge and purge) are in the normal weight range, with the remaining 10% percent overweight, rather than the underweight anorexic. A bulimic individual's weight will often fluctuate rather than uniformly decrease, and they are far more likely than anorexic individuals to have problems with petty theft (often stealing food to fuel binges).

Demographics and Causes

Bulimia was first described formally in 1979, but in all probability has been around for a lot longer. Since its classification, there have been problems in figuring out exactly how many people have the disorder - this is partly due to the confusion with anorexia as outlined above, but mostly because bulimia is often a very private illness that is easy to hide (unlike severe anorexia) and when discovered people don't always seek treatment.

Despite the uncertainty, bulimia may occur among as many as 1% of adolescent girls and young adult women in the West. It is less common in males (although approximately 10% of all individuals with eating disorders are male) and older individuals, and is rare outside of the Western world – but becoming more common.

Nobody knows what causes bulimia. It is probably a combination of different factors, similar (if not identical) to those of anorexia; factors include the Western obsession with the ever-decreasing ideal weight. Most eating disorders begin against a background of dieting.

Other personality traits and mental health problems that are linked to bulimia include perfectionism, obsessive-compulsive traits, depression or anxiety. A family history of eating disorders of any type makes you more likely to develop bulimia. Some reports estimate that as many as a quarter of bulimic individuals have a past history of childhood sexual abuse.


The understanding and support of individuals who have bulimia is very important. Bingeing fulfils an important psychological need for them and it is important to find out what that is. There are many support groups available for people with eating disorders (as well as their families) such as the National Eating Disorders Association (USA) and the Eating Disorders Association (UK). But the first and most important step in recovery is realising that you have a problem and seeking help for it. This can be a difficult and uncomfortable experience, as the gateway to eating disorder treatment services4 is most often through seeing a psychiatrist - seldom an appealing prospect for an adolescent.

Once care has been accessed, therapy can begin - this is usually individualised depending on each person's needs. Psychotherapy, particularly cognitive behavioural therapy (a type of psychotherapy that focuses on giving patients strategies to prevent and deal with negative thoughts), is the mainstay of treatment for most bulimic individuals, and hopefully should serve to allow the bulimic individual to deal with the underlying negative sense of body image and some of its societal triggers. If the bulimic individual is willing, therapy can also involve the surrounding family and enable them to support the affected individual as well.

While psychotherapy has been the most important and lasting intervention for bulimic individuals, it has also been shown to do better in combination with the judicious use of antidepressant medications such as nortriptyline, amitriptyline and fluoxetine (Prozac®). These medications have been shown to decrease the frequency of binge-eating and purging, but are not cures by themselves. Antidepressant medication is also often needed to deal with the depression that is common in bulimic individuals.

Bulimia can be overcome, but it often requires a lot of hard work and understanding on behalf of the affected individual and those around them.

Frequent binge-eating and/or purging is abnormal behaviour. If you, or somebody you know, has these symptoms then please seek help from a medical professional.

BBC Health
1Literally 'the nervous hunger of an ox.' Bulimia will be used throughout this Edited Guide Entry to refer to bulimia nervosa, for the sake of brevity.2Medications that make you pass water.3Medications that make you pass bowel motions.4Which are often inconsistently resourced and overworked, although this varies enormously depending on where you live.

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