Bulimia nervosa is an eating disorder characterized by periods of binge eating. In some cases, the person will compensate for this overeating by forcing vomiting; misusing laxatives, diuretics, or enemas; fasting; or excessive exercising. People with bulimia cannot control their eating and have a paralyzing fear of becoming fat. Bulimia is associated with depression and other psychiatric disorders and shares symptoms with anorexia nervosa, another major eating disorder. Because many individuals with bulimia maintain a normal or above-normal body weight, they are able to keep their condition a secret for years.

Bulimia is often accompanied by the following signs and symptoms:

• Binge eating of high-carbohydrate foods, usually in secrecy
• Loss of control over eating, with guilt and shame
• Body weight that goes up and down
• Constipation, diarrhea, nausea, gas, abdominal pain
• Dehydration
• Blood-tinged vomit
• Irregular menstruation or cessation of menstrual periods
• Eroded tooth enamel
• Bad breath
• Throat irritation and inflammation
• Calluses on hands from forcing the body to vomit
• Stealing, especially food
• Depression
• Substance abuse, especially alcohol

There are several different theories about what is involved in the development of bulimia. Bulimia may have a hereditary component; in addition, some experts believe that a family environment with an overemphasis on achievement may be another contributing factor. The role of sexual abuse in the development of bulimia is controversial. Other psychological and environmental factors may be involved; these include mood disorders and substance abuse in families of people with bulimia. Individuals with bulimia may also experience depression, self-mutilation, substance abuse, and obsessive-compulsive behavior. Cultural pressures to appear slender contribute to the disorder, particularly among dancers and athletes.

People with the following conditions or characteristics are at higher risk for developing bulimia:

• White, middle-class women (primarily adolescents and college students)
• People with a family history of mood disorders and substance abuse
• Individuals with low self-esteem

Often, people with bulimia are ashamed of their condition and do not seek help for many years, by which time their behaviors are deeply ingrained and harder to change. If you are experiencing symptoms associated with bulimia, you should see a healthcare provider as soon as possible. He or she will check for physical signs such as eroded tooth enamel and enlargement of the salivary glands, as well as signs of depression, possibly including marks from self-mutilation. Laboratory tests can reveal chemical changes caused by bingeing and purging, and psychological tests may point to obsessive-compulsive or antisocial behaviors.

The most successful treatment is a combination of interpersonal therapy, family therapy, patient education, and medication.

Your provider may prescribe the following medications:

• Fluoxetine, a selective serotonin reuptake inhibitor (SSRI) and currently the only FDA-approved drug for bulimia. Your doctor may also prescribe other antidepressants, such as other SSRIs, tricyclic antidepressants, or monoamine oxidase (MAO) inhibitors.
• Potassium supplementation

Psychotherapy is a cornerstone of bulimia treatment. Using biofeedback may also help you to better manage stress. Other mind-body and stress-reduction techniques, such as yoga, tai chi, and meditation, may help you become more aware of your body and form a more positive body image. A 6-week clinical trial showed that guided imagery helped people with bulimia reduce bingeing and vomiting, feel more able to comfort themselves, and improve their feelings about their bodies and eating. More studies are needed to verify these findings and to determine if guided imagery has long-term benefits.

Nutrition therapy is as important as psychotherapy in treating bulimia. The goals of nutrition therapy are to stabilize your blood sugar levels, to make sure you are getting enough nutrients, and to restore your gastrointestinal health. In one study, 55 women with bulimia were assigned at random to either a nutritional management treatment group or a stress management treatment group. Nutritional management included information on the effects of bulimia, techniques to avoid binge eating, and advice about making meals and eating. Women in this group also had their eating diaries analyzed. Stress management included analysis of stressful situations; short-term stress management strategies, such as relaxation, self-encouragement, and self-distraction; and training in planning, problem solving, and communication. Women in the nutritional management group reduced their binge eating faster and were better able to avoid bingeing over the next year.

Some people with eating disorders are deficient in zinc. Variations in levels of zinc can affect taste, smell, appetite, and response to stress. Zinc deficiency may play a role in eating disorders and altered self-image. Taking zinc supplements may help with your treatment. In a recent study of 47 women with bulimia, zinc supplements seemed to reduce their obsession with weight and concern with body image. Your healthcare provider may also recommend a multivitamin with minerals to maintain levels of other important nutrients. B-complex vitamins may reduce stress and depression.

If you have trouble recognizing feelings of hunger, your provider may recommend eating small meals every 3 hours.

While no scientific literature supports the use of herbs for bulimia, a trained naturopath or herbalist may recommend one or more of the following to alleviate stress, restore normal digestion and decrease anxiety:

• Licorice root (Glycyrrhiza glabra)
• Skullcap (Scutellaria lateriflora)
• Oatstraw (Avena sativa)
• Passionflower (Passiflora incarnata)
• Lemon balm (Melissa officinalis)

Additional herbs may be considered to treat particular symptoms such as St. John's wort (Hypericum perforatum) for depression. St. John's wort must not be used with other antidepressants or with several other medications; see monograph entitled St. John's wort and check with your doctor for details. Taking any of the herbs mentioned for this condition should be done under the direction of an appropriately trained and certified specialist who will guide your individual care accordingly.

No scientific literature supports the use of homeopathy for bulimia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.

No scientific literature supports the use of acupuncture for bulimia. However, a trained acupuncturist may be able to recommend acupuncture treatments to support your overall treatment.

Therapeutic massage can be an effective part of a bulimia treatment plan. In one study, adolescent women with bulimia were assigned at random either to receive massage therapy for 5 weeks or to be in a control group (not receiving massage therapy). The 24 women receiving massage improved immediately, while the control group did not improve. Women in the massage group were less anxious and depressed right after their initial massages. They also had better scores on the Eating Disorder Inventory, which helps providers assess psychological and behavioral traits in eating disorders.

Relapse is common in people with bulimia. Complications that can happen from repeated bingeing and purging include problems with the esophagus, stomach, heart, lungs, muscles, or pancreas. Suicidal individuals or those with severe symptoms may need to be hospitalized to prevent further complications. Pregnancy may be difficult emotionally for women with bulimia because of the changes in body shape that occur. Poor nutritional health of the mother may also have a negative impact on the unborn child. Women who have stopped menstruating because of bulimia will be unable to become pregnant.

Since bulimia is usually a long-term disease, the person's weight, exercise habits, and physical and mental health need to be checked periodically by a healthcare provider.

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