Signs and Symptoms

People with bulimia may have the following signs and symptoms:

• Binge eating of large amounts foods, usually in secret
• Exercising for hours or using laxatives, diet pills, or water pills
• Eating until painfully full
• Going to the bathroom during or immediately after meals
• Avoiding eating in public
• Losing control over eating, and feeling guilt and shame
• Damaged tooth enamel and diseased gums

Bulimia nervosa is linked to depression and other mental disorders. It shares some symptoms with anorexia nervosa, another major eating disorder.

What Causes It?

There is no single cause for bulimia. Multiple factors contribute to the development of this disorder, including:

• Genetic factors - eating disorders are more common in people with relatives with eating disorders.
• Psychological factors - many people with eating disorders also experience depression, anxiety disorders, and obsessive-compulsive disorder.
• Cultural factors - cultural pressure to look thin may also play a part.

Who Is Most At Risk?

These people are at higher risk for developing bulimia:

• Women - about 90% of people with eating disorders are women.
• People who have first degree relatives with an eating disorder.
• People with a history of emotional and physical trauma, impulsive personality traits, or diagnoses of depression, anxiety, and obsessive-compulsive disorder.

What to Expect at Your Provider's Office

Often, people with bulimia are ashamed of their condition and do not ask for help for many years. If you have symptoms of bulimia, talk to your doctor as soon as possible.

• The doctor will check for physical signs such as tooth cavities, enamel erosion, diseased gums, and enlarged salivary glands.
• Laboratory tests may show chemical changes caused by abnormal eating.
• Your doctor or a mental health practitioner will do a psychological exam and ask about your feelings and eating habits.
  

Treatment

Treatment Plan

People with bulimia may need a combination of treatment including:

• Psychotherapy
• Family therapy
• Nutritional rehabilitation counseling
• Medication

It is important for the person with bulimia to be actively involved in their treatment. Studies show cognitive behavioral therapy is remarkably effective in treating bulimia.

Drug Therapies

Doctors often prescribe antidepressants for bulimia, usually those called selective serotonin reuptake inhibitors (SSRIs). They include:

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)

Psychotherapy

Psychotherapy is a crucial part of bulimia treatment. Many people with bulimia have good results from cognitive behavioral therapy, which teaches you to replace negative thoughts and behaviors with healthy ones. Other psychotherapy approaches include interpersonal therapy, motivational enhancement therapy, and focal psychodynamic therapy. Family therapy is also an important component of recovery.

Complementary and Alternative Therapies

Mind-body and stress-reduction techniques, such as yoga, tai chi, and meditation may help you become more aware of your body and have a more positive body image.

Although there aren't any supplements that specifically treat bulimia, some may be good for your general health and well-being. Also, people with bulimia may fall short on some vitamins and minerals, which can affect their health. A better diet or taking supplements can help. Always tell your health care provider about any herbs and supplements you are thinking about using.

Follow these useful measures to overcome abnormal eating behaviors:

• Nutritional counseling
• Use of food diaries
• Planning meals one day in advance

Follow these nutritional tips for maintaining overall health:

• Avoid caffeine, alcohol, and tobacco.
• Drink 6 to 8 glasses of filtered water daily.
• Use quality protein sources -- such as lean meat and eggs, whey, and vegetable protein shakes -- as part of a balanced program to gain muscle mass and prevent wasting.
• Avoid refined sugars, such as candy and soft drinks.

If you have nutritional deficiencies, the following may be helpful:

• A daily multivitamin, as indicated by your doctor.
• Omega-3 fatty acids, such as fish oil, to help reduce inflammation and boost immunity. Cold-water fish, such as salmon or halibut, are good sources; eat 2 servings of fish per week. Fish oil supplements can increase the risk of bleeding, so ask your doctor before them. Eating fish doesn't cause the same risk.
• Coenzyme Q10, for antioxidant, immune, and muscular support. Pregnant and breastfeeding women should not take coenzyme Q. People who take blood pressure medication, blood-thinners such as warfarin (Coumadin), or chemotherapy drugs should not take CoQ10 without first asking their doctor.
• Probiotics (containing Lactobacillus acidophilus among other strains), to help your digestive health and boost the immune system. Refrigerate probiotic supplements for best results. People with autoimmune diseases, such as rheumatoid arthritis or psoriasis, or people with weakened immune systems should ask their doctor first.

There are no herbs proven as effective for treatment of bulimia.

People with eating disorders may misuse herbs or herbal supplements marketed as weight loss products. These products have not been tested for their safety and may have dangerous side effects. Products containing ephedrine alkaloids (such as Ephedra-containing herbal supplements) have been banned by the FDA due to serious health effects (such as stroke, seizures, and worsening of heart and kidney disease). However, other ephedra-free supplements may have similar side effects, especially when combined with caffeine, which causes heart rhythm problems. You should discuss with your health care provider before starting any treatment.

There are no studies on using homeopathy to treat bulimia.

Studies have found that acupuncture can be helpful in treating addictive behaviors and anxiety in general. That may help people with bulimia who are in recovery. One study had positive results on the improvement of quality of life in patients with bulimia using acupuncture in addition to their medical treatment.

Physical therapy approaches, including massage, yoga, and relaxation techniques can be effective as adjunct treatments of bulimia nervosa.

Therapeutic massage can be an effective part of a bulimia treatment plan. In one study, 24 teen girls who got massage therapy for 5 weeks had better behavioral outcomes did better than a group of girls who didn't get massage and were less anxious and depressed than their counterparts.

Bright light therapy (BLT) is a non-invasive treatment approach typically used for seasonal affective disorder and other types of depressive conditions. Because many people with bulimia binge-eat at night, BLT has repeatedly been tested as a potential therapy. Several studies demonstrated that BLT is effective in improving eating behaviors and mood in patients with bulimia nervosa.

Prognosis/Possible Complications

It's very common for people with bulimia to relapse after treatment. They may need long-term care.

Possible complications resulting from bingeing and purging include problems with the:

• Esophagus
• Teeth and gums
• Stomach
• Heart
• Pancreas

Women with bulimia may find pregnancy emotionally difficult because of the changes in their body shape. The mother's poor nutritional health can affect the baby. Women who have stopped having periods because of bulimia are unlikely to become pregnant.

People with suicidal thoughts or severe symptoms may need to be hospitalized.

Following Up

Bulimia is usually a long-term disease. A health care provider will need to check the person's weight, exercise habits, and physical and mental health on an ongoing basis.

Supporting Research

Beauchamp MT, Lundgren JD. A Ssystematic Rreview of Bbright Llight Ttherapy for Eeating Ddisorders. Prim Care Companion CNS Disord. 2016;18(5). PMID: 27835724 www.ncbi.nlm.nih.gov/pubmed/27835724.

Bozzatello P, Brignolo E, De Grandi E, Bellino S. Supplementation with omega-3 fatty acids in psychiatric disorders: a review of literature data. J Clin Med. 2016;5(8).pii: E67. PMID: 27472373 www.ncbi.nlm.nih.gov/pubmed/27472373.

Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2010;46(4):346-351. PMID: 20307823 www.ncbi.nlm.nih.gov/pubmed/20307823.

Fan L, Feng Y, Chen GC, Qin LQ, Fu CL, Chen LH. Effects of coenzyme Q10 supplementation on inflammatory markers: A systematic review and meta-analysis of randomized controlled trials. Pharmacol Res. 2017;119:128-136. PMID: 28179205 www.ncbi.nlm.nih.gov/pubmed/28179205.

Ferri, FF. Bulimia nervosa. In: Ferri FF, ed. Ferri's Clinical Advisor 2018. Philadelphia, PA: Elsevier Mosby; 2014: 225-226.e1.

Field T, Schanberg S, Kuhn C, et al. Bulimic adolescents benefit from massage therapy. Adolescence. 1998;33(131):555-563. PMID: 9831872 www.ncbi.nlm.nih.gov/pubmed/9831872.

Fogarty S, Harris D, Zaslawski C, McAinch AJ, Stojanovska L. Acupuncture as an adjunct therapy in the treatment of eating disorders: a randomised cross-over pilot study. Complement Ther Med. 2010;18(6):233-240. PMID: 21130359 www.ncbi.nlm.nih.gov/pubmed/21130359.

Fogarty S, Smith CA, Hay P. The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review. Eat Behav. 2016;21:179-188. PMID: 26970732 www.ncbi.nlm.nih.gov/pubmed/26970732.

Kowalska I, Karczewska-Kupczewska M, Straczkowski M, Rubin RT. Anorexia nervosa, bulimia nervosa, and other eating disorders. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 29.

Mason BL. Feeding systems and the gut microbiome: gut-brain interactions with relevance to psychiatric conditions. Psychosomatics. 2017;S0033-3182(17)30148-2. PMID: 28716445 www.ncbi.nlm.nih.gov/pubmed/28716445.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH: LexiComp; 2000:387-388.

Polnay A, James VA, Hodges L, Murray GD, Munro C, Lawrie SM. Group therapy for people with bulimia nervosa: systematic review and meta-analysis. Psychol Med. 2014;44(11):2241-2254. PMID: 24238470 www.ncbi.nlm.nih.gov/pubmed/24238470.

Sangvai D. Eating disorders in the primary care setting. Prim Care. 2016;43(2):301-312. PMID: 27262009 www.ncbi.nlm.nih.gov/pubmed/27262009.

Setnick J. Micronutrient deficiencies and supplementation in anorexia and bulimia nervosa: a review of literature. Nutr Clin Pract. 2010;25(2):137-142. PMID: 20413694 www.ncbi.nlm.nih.gov/pubmed/20413694.

Tanofsky-Kraff M. Eating disorders. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Sauders; 2016:chap 219.

Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil. 2014;36(8):628-634. PMID: 23826882 www.ncbi.nlm.nih.gov/pubmed/23826882.