A Closer Look at Bulimia Nervosa

Teen girl hiding and sitting in a dark bathroom while bingeing on spaghetti


Posted in: Parenting Concerns

Topics: Mental Illness + Psychiatric Disorders

For more information about eating disorders and ways you can help make a difference for a young person in your life, or for yourself, please visit the National Eating Disorder Association website. #NEDAwareness


In the United States, there has been a culturally driven obsession with weight loss and body image.

Just look at the models and actresses we see on television, in movies, in women’s magazines and online. Many studies have documented the impact of media on a drive to attain thinness. The pressures even begin in school age kids.

And in our own personal conversations, what do you hear, male or female, when you’ve lost 5-10 pounds? “You look GREAT!”

Fortunately, the impact of the media studies has made most of us aware of the ill effects on women in particular, and television has done an excellent job over the last decade in exposing us to a wide range of stars with different body sizes and shapes.

Bulimia Nervosa has been called “the secretive syndrome” because most of the folks who suffer from this disorder are normal or slightly above weight and hide their behavior. Their shame, often personal torture, makes it very different from women with Anorexia Nervosa.

Those with anorexia nervosa, though compulsively driven to thinness, are usually extremely gratified by refraining from eating and losing weight. Their eating disorder is not viewed as foreign from their personal experience. It is not an intrusion.

This is quite the opposite for bulimia nervosa. It feels like something foreign has taken over and is in the driver’s seat. Let’s begin with a vignette.


Karen was a sophomore in college. She was deeply involved in her sorority, loved to drink and party, and was a top student. She played on the school softball team. After meals, Karen would frequently leave abruptly to go to the bathroom. One time a friend happened to find her vomiting in the bathroom stall. Her friend had no clue whether to confront her or to keep it to herself. Karen would often hoard food, mostly carbohydrates, like loaves of bread, boxes of cookies or doughnuts, and frantically eat them late at night, then purge. She became clinically depressed, binged more and more frequently, increased her alcohol consumption, and had to take a medical leave of absence. No one knew exactly why she was out, other than knowing she was depressed and out of control at parties.

What is Bulimia Nervosa?

Bulimia Nervosa is a disorder that is characterized by episodes of eating a large amount of food in very short periods of time, with a feeling that there is no control of this behavior. It is an irresistible compulsion. Following binges, there is the impulse to compensate for the behavior by purging – and this might include vomiting, induced by one’s finger or taking some medication such as Ipecac, laxatives or diuretics, or going on a long run.

Binges typically occur on average once a week though sometimes multiple times a week. The purging behavior is tied to attempts to control body shape and weight.

From a psychological perspective, bulimia feels like an addiction. It feels like something the person cannot control, and often results in very low self-esteem, poor self-image, and is not a pleasant experience. It feels “disgusting” and “out of control.” – bulimia is a living torture. The intense shame often obstructs seeking help.

Associated Features

Bulimia tends to be three times more common in women than in men, and it typically begins in the late teens or early 20s.

People with bulimia nervosa often have personal characteristics that may not be severe enough to create dysfunction. These are the features we are born with. The traits often seen in folks with bulimia include perfectionism; compulsive behavior (need for control, exactness, and order); impulsivity (often associated with abrupt and, at times poor decision making); and narcissism (extreme needs for validation and admiration, self-centered behavior, excessive focus on image).

There are also a number of psychiatric disorders that are very common in people who have bulimia.

Depression is the most common associated disorder, and occurs in about 50% of cases. Other common associated problems include:

There are a number of risk factors for bulimia including childhood trauma, such as sexual abuse, and discontinuation of psychotherapy.

Of considerable importance is that, like many other mental health disorders, multiple factors have an added impact. For bulimia nervosa, a history of childhood maltreatment is often associated with depressive conditions, anxiety disorders, and borderline personality disorder. And in these cases the prognosis is worse.

Bulimia nervosa has been associated with personality disorder.

Many patients and family members ask about personality disorders and just what they mean. Personality disorders should not be confused with disorders of the “person.”  Rather, they are labels that indicate a constellation of behavioral, emotional and cognitive characteristics that cause problems in one’s social, occupational or academic, and recreation life. While I am not fond of the label “personality disorders” I understand that it is shorthand for looking at a cluster of qualities that more often than not are present together.

The most common personality disorder associated with bulimia is Borderline personality disorder. Borderline traits include:

  • difficult, often stormy interpersonal relationships;
  • intolerance or uncontrolled anger;
  • feelings of aloneness or emptiness;
  • seeing the world in black and white terms – as all good or all bad;
  • difficulty regulating emotions; low self-worth;
  • self-destructive behaviors such as suicide attempts, shoplifting, substance abuse, and impulsivity.

Medical Complications and Outcome

People who have bulimia nervosa often have complications that result from excessive purging, including:

  • dehydration;
  • loss of salts in the blood (electrolytes);
  • gastrointestinal problems, such as inflammation of the stomach or esophagus;
  • enlarged salivary glands (from eating excessive carbohydrates that stimulate saliva production);
  • erosion of dental enamel with increased risk of cavities, due to the acid in vomit.

The good news about bulimia is that, with treatment, 30-80% have a remission. Still, the recurrence rate is very high. This means that even with no symptoms present, ongoing care and attention to the underlying problems continue to need attention.


Treatment for bulimia nervosa can be highly effective.

It generally involves a team effort, including a primary care physician, nutritionist, and mental health clinicians.

The most important treatments include monitoring of medical and nutritional status, including possible medical complications and psychiatric care.

From the mental health standpoint, effective treatments include psychotherapy, most importantly, cognitive behavior therapy. Additional psychotherapy methods for many patients include mindful meditation, techniques to regulate emotions, and family therapy. Medications, and in particular the antidepressant medications are extremely valuable in diminishing binging and purging episodes. They also treat associated depression, anxiety and obsessive compulsive disorders if present, and diminish impulsivity. The selective serotonin reuptake inhibitors (SSRIs) are among the most effective antidepressant for bulimia nervosa.


Among the most important preventative measures are increasing knowledge of the illness, and using techniques to reduce the importance of body image and thinness for our kids – starting this as early as possible, at home and in school. Studies have also found that programs that can diminish the need for dieting and increase the emphasis on good nutrition and healthy eating patterns, without need for dieting, and improving emotional regulation all help.

Prevention is most effective for bulimia nervosa (and virtually all other mental health problems) if programs are conducted in all areas in which the child lives – at home, in school, in after school and community programs.

Now let’s go back to Karen:

Karen began seeking psychiatric treatment during her medical leave from college. For the initial phase of work, she was very reluctant to talk about the details of her binging and purging, and avoided talking about her body image. In time she earned trust began discussing details of her impulses to binge and purge. The goal was to increase the interval from the impulse to binge to the action. The longer the interval, the less powerful the impulse led to binging and purging.

What helped? Medication. Meditation. Use of humor. Looking at photos of women together with her therapist and candidly talking about how she compared herself to them. Discussing the exaggerated or distorted thoughts (cognitions) she had about her body, self, and relationship with others.

This progressed to discussing her use of alcohol, and her sexual, often promiscuous behavior in order to achieve positive self-esteem. And then considered other means of feeling good about herself, and ways of controlling her emotions. Her family came in to better understand her disorder and learn how to help out when she needed it. It also surfaced that, many years earlier, she had suffered sexual abuse from another kid in the neighborhood, which had a shameful and devastating impact on her. This was new news to her parents.

In about 3-4 months, Karen’s binging stopped. There were recurrences, she did not let them derail her. She continued to stay in touch with her therapist, and has continued to work on this over the 10 years following her return to school.

Young people like Karen need an anchor in their lives who will not give up on them, despite the ups and downs. This is a marathon, not a sprint, but it is worth doing in support of every single young person who needs the help.

If you or a young person in your life is in need of help, and you are not sure where to begin, you start searching for help and support through the National Eating Disorder Association (NEDA).

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Gene Beresin

Gene Beresin, Executive Director

Gene Beresin, MD, MA is executive director of The MGH Clay Center for Young Healthy Minds, and a staff child and adolescent psychiatrist at Massachusetts General Hospital. He is also...

To learn more about Gene, or to contact him directly, please see Our Team.