Skip to main content

Verified by Psychology Today

Bulimia nervosa is an eating disorder characterized by episodes of binge eating—consuming a large amount of food very quickly—followed by compensatory behavior, most commonly vomiting or "purging" or the abuse of diuretics or laxatives.

People who are bulimic often feel a lack of control over their behavior. They typically know they have a problem yet often fear they are unable to stop engaging in binges, leading them to engage in purging behaviors in an attempt to avoid weight gain. Binging and purging are often performed in secret, with feelings of shame alternating with relief.

Unlike those with anorexia, people with bulimia are often able to maintain a normal weight for their age; they may even be overweight or obese. But similar to people with anorexia, they tend to fear gaining weight, desperately want to lose weight, and are intensely unhappy with their body size and shape. The binging and purging cycle is usually repeated several times a week. As with anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety, and substance abuse problems. Many physical dysfunctions can result from purging, including electrolyte imbalances, gastrointestinal troubles, and dental problems.

Bulimia nervosa can affect individuals of any race, age, or gender; however, it is significantly more common in women and girls than it is in men and boys. Approximately 3 percent of females have bulimia nervosa during their lifetime, compared to an estimated 1 percent of males. It is more common in adolescents and young adults than in other age groups.


According to DSM-5, common symptoms of bulimia nervosa include:

  • Recurrent episodes of binge eating, characterized by eating within a discrete period of time (usually two hours or less) an amount of food substantially larger than most people would eat
  • A feeling that one cannot stop eating or control what or how much one eats
  • Recurrent compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; and/or excessive exercise
  • Self-evaluation unduly influenced by body shape and weight

In addition to behavioral and psychological symptoms, physical symptoms of bulimia nervosa may include:

  • Chronically inflamed and sore throat
  • Swollen glands in the neck and below the jaw
  • Worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acids
  • Acid reflux disorder (gastroesophageal reflux disorder, or GERD)
  • Intestinal distress and irritation from laxative abuse
  • Kidney problems from diuretic abuse
  • Severe dehydration from the purging of fluids
  • Sores or scabs on the knuckles if hands are used to induce vomiting

Bulimia is categorized as mild, moderate, severe, or extreme based on the number of inappropriate compensatory behaviors that happen each week.

What are common warning signs of bulimia?

Though many people with bulimia go to great lengths to keep their disorder a secret, there may be several key warning signs that concerned friends and family may notice. Potential red flags include a preoccupation with food, weight, or body size; frequent bathroom trips during or after meals; discomfort with eating in public or eating in front of other people; or a tendency to exercise to excess. Loved ones may also notice physical symptoms such as a swollen face, damaged teeth, sores or scars on the hands or knuckles, or rapidly changing weight. 

At what age does bulimia usually start?

Many cases of bulimia begin in the late teens and early 20s, though the disorder can go undetected until the 30s or 40s. While late-life eating disorders are less common, it is possible for older adults to develop bulimia nervosa or experience a recurrence of the disorder; one study found that as many as 13 percent of women over age 50 engage in some kind of disordered eating behavior.


article continues after advertisement

There is no single known cause of bulimia, but there are some factors that are thought to play a part in the disorder’s development. These include biological factors such as genes and hormones; eating disorders are thought to have a strong genetic component, and some evidence suggests that hormonal changes that occur during adolescence and midlife may trigger disordered eating behavior, especially in teen girls and perimenopausal women. Other contributing factors include cultural ideals that prioritize and reward thinness, especially in women; a family history of disordered eating, crash dieting, or a familial preoccupation with food and weight; personality traits such as low self-esteem and/or high impulsivity; or major life changes and stressful or traumatic events, such as being sexually assaulted.

What triggers episodes of binging and purging?

A binge can be triggered by stress or other uncomfortable emotions, like anger, sadness, or low self-esteem. It may also occur in response to overly strict dietary restrictions and the feelings of hunger that result. Afterward, purging and other actions to prevent weight gain are typically undertaken to help those with bulimia feel more in control of their eating behavior and to ease the additional stress and anxiety triggered by the binge. Typically, neither binging nor purging offers any lasting relief from negative emotions and often serves to only exacerbate them. 

Can bulimia be prevented?

Because bulimia can stem from a combination of factors, there is no known way to consistently prevent it. However, experts suggest that promoting a positive body image and cultivating a healthy relationship with food—at home, at school, and elsewhere—can help children put less stock in cultural messaging that moralizes weight and dietary choices and learn to live peacefully with their bodies. Experts also suggest that regular family mealtimes and the gentle promotion of healthy habits can help children develop a positive relationship with food. Conversely, parents who regularly talk about weight or undergo fad diets may wish to take steps to change their behavior—both for their children’s benefit and for their own.


As with other eating disorders such as anorexia, treatment for bulimia often involves a combination of options and depends on individual needs.

To reduce or eliminate binging and purging, a patient may undergo nutritional counseling and psychotherapy, especially cognitive-behavioral therapy, and be prescribed medication. Some antidepressants—such as fluoxetine (Prozac), the only medication approved by the FDA for treating bulimia—may help patients who also suffer from depression and anxiety. The drug also appears to help reduce binge-eating and purging as well as the chance of relapse, and it can improve eating attitudes.

Cognitive-behavioral therapy tailored to the treatment of bulimia has also been shown to be effective in changing binging and purging behavior and improving attitudes towards eating. Therapy may be done one-on-one or in a group setting.

Eating disorders are complex and challenging, and behavioral, psychological, and neuroscience research on eating disorders is ongoing into causes and treatments. Researchers are also working to define the basic processes involved in the disorders, to understand risk factors, to identify biological markers of the disorder, and to develop medications that target specific pathways affecting eating behavior. Neuroimaging and genetic studies may provide clues for individual responses to specific treatments.

What is the first-line treatment for bulimia nervosa?

Treatment usually includes a mix of psychotherapy, nutritional support, and sometimes medication, and multiple therapeutic approaches have been used and shown to be effective. Cognitive-behavioral therapy (CBT), family-based treatment (FBT), or interpersonal psychotherapy (IPT) are commonly used to treat bulimia; children and adolescents may be more likely to be treated with FBT, as their recovery often needs to involve other family members to some degree. Psychotherapy for bulimia focuses on the maladaptive thought processes or relationship habits that drive binging and purging, as well as the depression and anxiety that frequently co-occur with bulimia. In nutritional therapy, a dietitian will work with the patient to help them make healthier food choices and learn to better recognize their body’s signals. Medications such as Prozac or other antidepressants can be prescribed for additional symptom support as needed.

Does bulimia treatment require hospitalization?

Most bulimia treatment can be done in an outpatient capacity. However, in very serious cases or in cases where the physical effects of bulimia have become life-threatening, hospitalization and/or in-patient care may be called for.

Tith R.M., Paradis G., Potter B.J., et al. Association of Bulimia Nervosa With Long-term Risk of Cardiovascular Disease and Mortality Among Women. JAMA Psychiatry. 2020;77(1):44–51. doi:10.1001/jamapsychiatry.2019.2914
Arcelus J., Mitchell A.J., Wales J., Nielsen S.. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011;68(7):724–731. doi:10.1001/archgenpsychiatry.2011.74
McLean, S. A., Paxton, S. J., & Wertheim, E. H. (2010). Factors associated with body dissatisfaction and disordered eating in women in midlife. The International journal of eating disorders43(6), 527–536.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  
American Psychiatric Association Work Group on Eating Disorders
National Institute of Mental Health
U.S. Department of Health and Human Services
Last updated: 03/25/2022