Bulimia Nervosa
Bulimia nervosa is a serious eating disorder involving cycles of binge eating followed by behaviors to compensate for it—driven by a preoccupation with body weight and shape that affects how a person feels about themselves.
What is bulimia nervosa?
Bulimia nervosa has three core features. First, recurrent episodes of binge eating—consuming an unusually large amount of food in a short window of time, with a feeling of being out of control and unable to stop. Second, repeated compensatory behaviors intended to prevent weight gain after a binge. Third, self-worth that is excessively tied to body shape and weight.
To meet the diagnostic criteria, binge eating and compensatory behaviors must both occur at least once a week on average over three months. Importantly, bulimia nervosa is a separate diagnosis from anorexia nervosa—if binge-purge behavior occurs only during episodes of anorexia, bulimia nervosa is not diagnosed separately.
Unlike anorexia nervosa, people with bulimia are typically within a normal or overweight weight range, which means the condition is often hidden and can go unrecognized for a long time.
What is a binge eating episode?
A binge eating episode involves two things happening together: eating a distinctly larger amount of food than most people would eat in similar circumstances and a similar time period—usually under two hours—and a clear sense of loss of control, feeling unable to stop eating or to choose what or how much is consumed.
Binges are most commonly triggered by negative emotions such as stress, anxiety, low mood, or boredom, as well as by strict dieting or negative feelings about one's body. Episodes are typically followed by intense feelings of shame, guilt, or distress.
Compensatory behaviors
To try to undo or offset a binge, people with bulimia nervosa engage in compensatory behaviors. These may include:
- Self-induced vomiting
- Misuse of laxatives or diuretics
- Misuse of other medications
- Fasting
- Excessive exercise
Between binge episodes, many people also restrict their food intake significantly, which can set the stage for the next binge by increasing hunger and preoccupation with food.
How severity is measured
Severity is based on the average number of compensatory behaviors per week:
Severity may also be raised to reflect the degree of functional impairment and other symptoms present.
Signs and symptoms
Because people with bulimia nervosa are often a typical weight, signs can be subtle. Common things to look for include:
- Evidence of binge eating—disappearing large amounts of food, food wrappers hidden away
- Disappearing to the bathroom shortly after meals
- Swollen cheeks or jaw (enlarged salivary glands from repeated vomiting)
- Dental erosion or tooth sensitivity
- Calluses or scars on the knuckles from inducing vomiting
- Fluctuations in weight
- Intense preoccupation with food, weight, or body shape
- Mood changes—irritability, low mood, anxiety—particularly around mealtimes
- Withdrawing from social situations involving food
Physically, repeated purging can cause electrolyte imbalances that affect the heart, dehydration, damage to the esophagus, and gastrointestinal problems.
How common is it?
Bulimia nervosa occurs across all ethnoracial groups in the United States. However, treatment utilization tends to be lower among underserved populations, and men are underrepresented in treatment samples—meaning the condition is likely underdiagnosed in those groups.
When does it start and how does it progress?
Bulimia nervosa typically begins in adolescence or young adulthood, and onset often follows a period of dieting. The course can be chronic or intermittent, with periods of improvement and relapse. Longer periods of remission—over a year—are associated with better long-term outcomes.
In a minority of cases (around 10–15%), people initially diagnosed with bulimia nervosa may later develop anorexia nervosa. Having co-occurring psychiatric conditions tends to predict a more difficult course.
Risk factors
Temperament and personality
Low self-esteem, depressive symptoms, and anxiety—including childhood generalized anxiety disorder—are associated with increased risk. People who are highly self-critical or prone to negative thinking about their body may be particularly vulnerable.
Environment
Internalizing the cultural ideal of thinness and childhood experiences of trauma, including physical or sexual abuse, are linked to higher risk.
Genetics and biology
Bulimia nervosa runs in families. Biological factors such as early puberty and childhood obesity are also associated with increased risk, possibly through their effects on body image and dieting behaviors.
Bulimia nervosa and suicidal thoughts
Bulimia nervosa is associated with elevated suicide risk. Approximately one in four people with the condition report suicidal ideation, and a similar proportion have attempted suicide. If you or someone you know is struggling, please reach out for help.
988 Suicide & Crisis Lifeline: Call or text 988 (available 24/7 in the U.S.)
Conditions that often occur alongside bulimia nervosa
Bulimia nervosa commonly occurs alongside other mental health conditions:
- Depressive disorders
- Bipolar disorders
- Anxiety disorders
- Substance use disorders (affecting at least 30% over a lifetime)
- Personality disorders, especially borderline personality disorder
Co-occurring conditions often need to be addressed as part of treatment for the best outcomes.
What to do next
Bulimia nervosa is very treatable, and many people recover fully with the right support. Cognitive behavioral therapy (CBT) is the most evidence-based treatment and is effective for most people. Antidepressants—particularly SSRIs—are also shown to reduce binge-purge frequency. A combination of therapy and medication often works best, alongside nutritional support to help establish a regular, balanced eating pattern.
If you recognize these patterns in yourself or someone you care about, reaching out to a GP or mental health professional is a good first step. You do not need to be in crisis to deserve help—early support leads to better outcomes.