Bulimia nervosa

Learn about bulimia, signs to look for, how your doctor determines if you have an eating disorder and treatment options
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Found in: Mental Health Conditions
Date: March 2023

About bulimia nervosa

Bulimia nervosa is an eating disorder that affects the way you eat and the way you feel about food and your body. People with bulimia repeatedly binge eat – eat large amounts in one sitting, with a loss of control – and engage in ‘purging’ behaviours such as vomiting and restricting behaviour to compensate for the food they have eaten.  

You may want to read this article on eating disorders first, and then come back here for bulimia nervosa in particular. The article explains that eating disorders are much more than an extreme focus on diet and exercise. They are not a ‘phase’ or a ‘choice’, and it is extremely hard to recover from them without professional help. However, with the right treatment and support, you can make a full recovery.

Who gets bulimia nervosa?

Bulimia most often begins in adolescence or early adulthood, but it can affect people of all ages, genders, races and social groups. Sadly, the stereotype of bulimia nervosa affecting only young women can sometimes stop other people from getting the help they need.

Bulimia is often associated with other mental health conditions. If you have bulimia, you may also experience symptoms of anxiety, depression, attention deficit hyperactivity disorder (ADHD), or substance-use disorder (SUD). You may engage in self-harming behaviours when feeling distressed. Your clinician can help design a treatment plan for you that takes all these factors into account.


Signs to look for (symptoms)

These symptoms are present in all people who get a diagnosis of bulimia:

  • Repeated episodes of binge eating (eating large amounts in one sitting, with a feeling that you have no control)
  • Repeated purging behaviour (vomiting; using laxatives, enemas or diuretics; fasting; or exercising excessively to compensate for the food you have eaten)
  • A strong belief that your body size or shape impacts your value as a person

If you are experiencing bulimia, you – or the people around you – may notice some of the following behaviours, feelings and physical symptoms. It’s important to remember that bulimia can affect people of any weight and body shape. Even if you look ‘healthy’ to other people, or your medical tests come back normal, you may still be seriously unwell.  

  • The way you eat: Preferring to eat alone or secretly, being dishonest about what you’ve eaten, finding it hard to stop eating even when you’re full.
  • Your attitude towards your body: Low self-esteem, feeling dissatisfied with your body, thinking or talking a lot about losing weight or being ‘fat’, wearing baggy or layered clothes to disguise weight loss, asking people for reassurance about your body size, weighing/pinching/looking in the mirror obsessively, strong interest in images and information about weight loss/thin people.
  • The way you exercise: Exercising in secret, exercising intensely with no pleasure, developing rituals around exercise, exercising to compensate for eating.  
  • Signs of purging: Sore throat, tooth decay, bad breath, a rounder face from swollen glands, swollen/red marks on fingers or knuckles, using diet pills/laxatives/diuretics/enemas, going to the bathroom straight after meals, running water in the bathroom to cover vomiting sounds, using mints or gum to cover the smell of vomit.   
  • Physical symptoms: Fluctuations in weight, weight change after illness/travel/increased involvement in sport or exercise, brittle nails, hair thinning/breaking/falling out, dry skin, downy hair on body, abnormal blood count, irregular heart rhythms, low pulse, low blood pressure, constipation, stomach pains, periods stopping/becoming irregular/delayed in starting, dehydration, loss of bone mass, feeling cold (especially hands and feet), fainting/dizziness, skin problems, lethargy/tiredness. 
  • Other behaviours: Struggling to sit still, having rigid (black-and-white) thinking, increased perfectionism, seeing other people as judgmental, becoming more isolated and socially withdrawn, difficulty talking about emotions.


Bulimia can have severe health consequences if left untreated, including damage to your teeth, mouth and digestive tract. Purging behaviour can lead to dangerous electrolyte imbalances, especially hypokalaemia, which can affect the way your heart functions. It’s important to monitor this through regular blood tests, and your GP may prescribe you potassium supplements.

Treatment options

Talking Therapies

There are several types of therapy that are proven to be effective in treating bulimia. This includes individual therapy, family therapy and guided self-help. It can sometimes include nutritional advice and meal planning with a dietician and education for you and your family/whānau.

In addition to specialist psychological treatment, you may be prescribed the antidepressant fluoxetine, as higher doses have been shown to reduce the frequency of binge-purge behaviours in bulimia. 

General counselling has not been shown to be effective in treating eating disorders. Make sure your clinician is trained in specialist eating disorder treatment, experienced in treating your type of symptoms, and being supervised for their work.

Below are some of the therapeutic approaches used to treat bulimia. Your clinician can help you decide which one is right for you.

  • Cognitive Behavioural Therapy (CBT-E) is the first line of treatment for bulimia. It focuses on patterns of thought and behaviour that are happening in the present day, rather than experiences in your past. You will work together with your therapist to explore and understand your patterns of thought and behaviour that contribute to disordered eating and learn techniques to change these.
  • Family Based Treatment (FBT) was originally designed to treat adolescents and young adults with anorexia but has been shown to be effective in a modified form for adolescents with bulimia too. Therapists, parents and the adolescent work together to help the young person’s recovery, stopping binging and purging behaviours and, if necessary, restoring weight. The treatment usually lasts for up to 20 sessions.
  • Integrative Cognitive Affective Therapy (ICAT) is a structured short-term treatment for bulimia, over 20 sessions. It focuses on the emotions that lead to a binge/purge episode, so you can increase your awareness and learn new techniques to manage these emotions.

All types of therapy/counselling should be provided to you and your family/whānau in a manner that is respectful of you, and that helps you feel comfortable and free to ask questions. It should be consistent with and incorporate your cultural beliefs and practices. All psychological therapies are designed to be done without disrupting study or work.

Other strategies to support recovery

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments that differ from conventional western medicine and which may be used to complement and support it.

Certain complementary therapies may enhance your life and help you to maintain wellbeing. In general, mindfulness, hypnotherapy, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress.

Family/whānau support and involvement

If someone you love is experiencing bulimia, you are likely feeling many emotions: fear, sadness, worry, frustration and more. It’s important to remember that eating disorders are strongly influenced by biology: it is not your fault that your loved one has bulimia, and it’s not something they can change or recover from without professional help.

As a family/whānau member, you have an important role to play. Learning as much as you can about bulimia and its treatment will reassure you and help you support both their recovery and your own wellbeing. Reach out to your own support network for practical help, seek counselling for yourself, and remember to care for your own physical and mental health.

Thanks to Dr Roger Mysliwiec, Director New Zealand Eating Disorders Clinic, for reviewing this content.
Date last reviewed: March 2023