Signs and Symptoms

People with bulimia may have the following signs and symptoms:

• Binge eating of high-carbohydrate foods, usually in secret
• Exercising for hours
• Eating until painfully full
• Going to the bathroom during meals
• Losing control over eating, and feeling guilt and shame
• Weight that goes up and down
• Constipation, diarrhea, nausea, gas, abdominal pain
• Dehydration
• Missed periods or lack of menstrual periods
• Damaged tooth enamel
• Bad breath
• Sore throat or mouth sores
• Depression

What Causes It?

No one knows what causes bulimia, although there are several theories. Genes may play a part. Women who have a sister or mother with bulimia may be at higher risk of developing the condition.

Families may put too much emphasis on achievement, or be overly critical. Psychological factors may also play a part including having low self esteem, not being able to control impulsive behaviors, and having trouble expressing anger.

Some people with bulimia may have a history of sexual abuse. People with bulimia may also have a history of depression, self mutilation, substance abuse, and obsessive-compulsive behavior.

Cultural pressures to look thin can also play a part, particularly among dancers and athletes. In one study, researchers found that patients with bulimia were likely to experience eating and shape / weight criticism in the year preceding the development of the disorder.

Who Is Most At Risk?

These people are at higher risk for developing bulimia:

• White, middle-class women -- mostly teenagers and college students
• Those with a family history of mood disorders and substance abuse
• People with low self esteem

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. By then, their habits are harder to change. If you have symptoms of bulimia, talk to your doctor as soon as possible.

The doctor will check for physical signs such as thin tooth enamel and enlargement of the salivary glands, as well as signs of depression. Laboratory tests may show chemical changes caused by bingeing and purging. Your doctor or a mental health practitioner will do a psychological exam and ask about your feelings and your eating habits.

Treatment

Treatment Plan

People with bulimia may need a combination of treatment including psychotherapy, family therapy, and 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)

Prozac is the only antidepressant approved by the Food and Drug Administration to treat bulimia. Some studies suggest that similar drugs, such as Luvox, may work even better.

Some studies have found that Prozac and other antidepressants may cause some children and teenagers to have suicidal thoughts. Children who take these drugs should be watched very carefully for signs of suicidal behavior.

People with bulimia may not be getting the nutrients their bodies need. Your health care provider may prescribe potassium or iron supplements, or other supplements to make up for any loss. Preliminary studies suggest a drug called zonisamide may also be effective in treating bulimia.

Complementary and Alternative Therapies

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 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. One 6-week clinical trial showed that guided imagery helped people with bulimia reduce binging and vomiting, feel more able to comfort themselves, and feel better about their bodies and eating. More studies are needed to see if guided imagery has long-term benefits.

Always tell your health care provider about any herbs and supplements you are thinking about using.

Nutrition and Supplements

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.

Follow these nutritional tips:

• 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, your doctor may suggest the following:

• A daily multivitamin, with the antioxidant vitamins A, C, E, the B vitamins, and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 to 2 capsules or 1 tablespoonful oil, 2 to 3 times daily, to help reduce inflammation, boost immunity, and improve mood. Cold-water fish, such as salmon or halibut, are good sources; eat 2 servings of fish per week. Fish oil can increase the risk of bleeding, so ask your doctor before taking it. Eating fish doesn't cause the same risk.
• Coenzyme Q10, 100 to 200 mg at bedtime, for antioxidant, immune, and muscular support. People who take blood pressure medication, blood-thinners such as warfarin (Coumadin) or chemotherapy drugs should not take CoQ10 without first asking their doctor.
• Probiotic supplement (containing Lactobacillus acidophilus among other strains), 5 to 10 billion CFUs (colony forming units) a day, 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.

Herbs

Herbs may strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting any treatment.

These herbs are not used to treat bulimia specifically. But they may be good for overall health and stress management:

• Holy basil ( Ocimum sanctum ) standardized extract, for stress. You can also prepare teas from the plant. Holy basil may make some blood thinners stronger, such as warfarin (Coumadin), clopidogrel (Plavix), and aspirin. Holy basil also interacts with pentobarbital (Nembutal), a sedative.
• Catnip ( Nepeta spp. ), as a tea 2 to 3 times per day, to calm the nerves and soothe the digestive system. Pregnant and breast feeding women, and women with pelvic inflammatory disease, should ask their doctors before taking catnip. Stop taking catnip at least 2 weeks before surgery. Catnip may interact with lithium and sedative medications.

Homeopathy

There are no scientific studies on using homeopathy to treat bulimia. However, an experienced homeopath will consider your individual case and may recommend treatments for both your underlying condition and any current symptoms.

Acupuncture

There are no scientific studies on using acupuncture to treat bulimia. However, a trained acupuncturist may be able to recommend treatments for your overall health. Many inpatient treatment centers for eating disorders include acupuncture in their treatment plan. 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.

Massage

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 did better than a group of girls who didn't get massage. Massage worked quickly, too. Women in the massage group were less anxious and depressed right after their first massages. They also had better scores on the Eating Disorder Inventory, which helps health care providers assess psychological and behavioral traits in eating disorders.

Prognosis/Possible Complications

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

Possible complications from repeated bingeing and purging include problems with the esophagus, stomach, heart, lungs, muscles, or pancreas. People with suicidal thoughts or severe symptoms may need to be hospitalized.

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.

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

Barabasz M. Efficacy of hypnotherapy in the treatment of eating disorders. Int J Clin Exp Hypn. 2007 Jul;55(3):318-35. Review.

Bodell LP, Joiner TE, Keel PK. Comorbidity-independent risk for suicidality increases with bulimia nervosa but not with anorexia nervosa. J Psychiatr Res. 2013; 47(5):617-21.

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 Apr;46(4):346-51.

Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 17th ed. New York, NY: McGraw-Hill; 2008.

Ferri: Ferri's Clinical Advisor 2015, 1st ed. Philadelphia, PA: Mosby, An Imprint of Elsevier; 2014.

Goncalves SF, Machado BC, Martins C. Eating and weight/shape criticism as a specific life-event related to bulimia nervosa: a case control study. J Psychol. 2014; 148(1):61-72.

Guerdjikova AI, Blom TJ, Martens BE, Keck PE, McElroy SL. Zonisamide in the treatment of bulimia nervosa: an open-label, pilot, prospective study. Int J Eat Disord. 2013; 46(7):747-50.

Jones A, Clausen L. The efficacy of a brief group CBT program in treating patients diagnosed with bulimia nervosa: a brief report. Int J Eat Disord. 2013; 46(6):560-2.

Kronenberg, HM ed. Williams Textbook of Endocrinology . 11th ed. Philadelphia, Pa: W.B. Saunders; 2008.

Krysanski VL, Ferraro FR. Review of controlled psychotherapy treatment trials for binge eating disorder. Psychol Rep . 2008 Apr;102(2):339-68. Review.

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

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatr Int. 2000;42:76-81.

Poulsen S, Lunn S, Daniel SI, et al. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. Am J Psychiatry. 2014; 171(1):109-16.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin . 2001;17(1):239-47.

Setnick J. Micronutrient deficiencies and supplementation in anorexia and bulimia nervosa: a review of literature. Nutr Clin Pract . 2010 Apr;25(2):137-42. Review.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr . 2002;21(6):495-505.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs . 2000;9(9):2103-19.

Wheatland R. Alternative treatment considerations in anorexia nervosa. Med Hypotheses . 2002;59(6):710-5.

Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008 Jan 15;77(2):187-95. Review.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J . 2005;46(5):585-96.