How does bulimia begin

Bulimia (bulimia nervosa)

Bulimia - in a nutshell

Bulimia (bulimia nervosa, addiction to eating and vomiting) is one of the psychological disorders. It is an eating disorder.

Who is affected?

Research has shown that around 0.5 to 1.2 percent of women between the ages of 12 and 35 are affected. The eating disorder often begins in late teens. Only every tenth patient is male.

Sometimes bulimia is preceded by another eating disorder, such as anorexia nervosa or binge eating disorder - also an eating disorder with binge eating.

What are Bulimia Symptoms?

A typical symptom of bulimia is repeated, uncontrollable binge eating. Those affected consume large amounts of food, often easily available high-calorie foods such as sweets, within a short period of time. They then take countermeasures to prevent possible weight gain, such as deliberately provoked vomiting, excessive exercise, fasting, or abuse of laxatives. Those affected often lead a kind of “double life”. Outsiders usually have no idea of ​​the disease. Unlike anorexia, bulimia is hardly noticeable when you are underweight. Bulimia sufferers are often rather slim, but mostly of normal weight.

Often people with bulimia fluctuate between two extremes in their eating behavior - strict control and total loss of control:

In public, bulimia sufferers often appear very controlled, they attach particular importance to a healthy diet, pay close attention to their weight, choose foods and dishes carefully, and avoid unhealthy "fattening foods".

In between these controlled phases, however, those affected repeatedly experience moments in which they completely lose control of their eating behavior. They then consume huge amounts of food, often particularly high-calorie, unhealthy or "forbidden" foods in their eyes. It seems impossible for them to stop eating at this point. Such binge eating occurs at different rates - sometimes weekly, daily, or even several times a day. Typically, they take place in secret.

Subsequently, the sick often feel shame and disgust. They fear gaining weight from the binge eating. That is why they take measures to undo their "binge eating". Some "stick their fingers down their throats" to induce vomiting. Others exercise excessively to burn calories. You are strictly fasting or abusing laxatives and diet pills.

Signs that can - but do not have to - indicate bulimia include:

  • Eating in public is avoided ("I've already eaten.")
  • Hidden, secret food. People with bulimia often do not have a regular meal
  • People often know unusually well about the calories, carbohydrates, and fats in food
  • Constantly counting calories or having a great deal of worry about your own weight can be a sign
  • The personal weight limit is usually chosen to be very low
  • Only selected, "healthy" foods are eaten in the presence of others
  • Those affected may buy large amounts of cheap, unhealthy, high-calorie foods
  • You may spend a lot of money on groceries - up to and including debt
  • Some sufferers hoard and hide food
  • The use of laxatives and water tablets can be an indication
  • An increased urge to move around and excessive physical activity may be associated with the disease
  • With some sufferers a swelling in the facial area, more precisely the salivary glands, is noticed, they get "hamster cheeks" or tooth damage

What are the health consequences of bulimia?

Bulimia can cause serious physical consequences over the long term. Those affected often do not suffer from significantly underweight, as is the case with anorexia. However, it is not uncommon for the diet to remain unbalanced overall. Then deficiency symptoms can occur.

However, underweight and bulimic vomiting can also occur together, in which case one speaks of bulimic anorexia.

If important nutrients are missing, this has a negative effect on the whole organism. Hair loss, poor concentration or susceptibility to infections are possible consequences. If you are underweight or if your body weight fluctuates significantly, menstrual disorders (for example, a lack of menstrual bleeding) are possible, as well as sleep disorders or phases of low blood sugar (hypoglycaemia). People with bulimia very often suffer from unstable mood and depressive phases.

However, damage to health is mainly caused by frequent vomiting. Gastric juice is constantly being lost. This can disrupt the body's salt and mineral balance (electrolyte balance) and lead to electrolyte imbalances. In severe cases, there is a risk of kidney damage, fluid retention or serious, sometimes life-threatening cardiac arrhythmias - especially due to a potassium deficiency (hypokalaemia).

When you vomit, aggressive stomach acid repeatedly gets into the esophagus and mouth. This puts a strain on the lining of the esophagus, which can become inflamed (esophagitis). Tooth enamel degradation and tooth decay can be other consequences.

Abuse of laxatives can also easily lead to electrolyte imbalances, but also indigestion and constipation. Digestive disorders can also arise from repeated binge eating. The stomach and intestines are excessively stretched and stressed.

The parotid glands can enlarge as a result of excessive stress, and sometimes even become inflamed.

Bulimia - the soul suffers

Bulimia is by no means an "alternative form of diet", but a psychological disorder - from which those affected usually cannot find out for themselves without suitable therapy.

Even if it may hardly be recognizable from the outside, the sick are under great pressure internally, suffer from their illness and their life situation. Many are ashamed or even hate themselves for their binge eating. Quite a few are withdrawing more and more from friends and family. Some suffer from dejection, depression or other mental disorders such as anxiety or compulsions. Bulimia is not infrequently associated with self-harming behavior, self-loathing, excessive alcohol consumption, and suicidal ideation.

Causes: what triggers bulimia?

Bulimia does not have a single cause. As with most mental disorders, it is very likely that different triggers come together. Individual personality and disposition play just as much a role as experiences, upbringing and the environment. Unrealistic ideals of beauty and dissatisfaction with one's own body can lead to impaired body awareness and thus contribute to the development of the disease. Family or school problems sometimes have an impact, as do conflicts in dealing with friends or colleagues. Hereditary factors and a genetic predisposition also play an important role according to the current state of knowledge.

Which factors are particularly important in individual cases can possibly be uncovered with the help of a therapy. Bulimic behavior sometimes also develops from another eating disorder (most notably anorexia).

Therapists also observe certain personality traits that apply to many - but by no means all - bulimia patients: some suffer from a rather low self-esteem and have a negative image of themselves and their bodies. At the same time, they feel that their surroundings have particularly high expectations, and sometimes feel overwhelmed. Some also put themselves under great pressure to perform, are ambitious and perfectionist.

Many bulimic people also tend to think "black and white", nuances are not perceived - they fluctuate between size fantasies and fear of failure, between "I can do anything" and "I can do nothing, I am worthless". They often have problems perceiving their own feelings and needs. For example, they do not feel that they are tired, hungry, or angry. Many have difficulty doing something good for themselves, indulging in something.


Bulimia, unlike other eating disorders such as anorexia, is not associated with abnormal and very low body weight. Many bulimic men and women keep their eating disorder well hidden. Often even parents, close friends or partners do not notice anything about the disease.

However, people with bulimia often know very well that they have an eating disorder. However, they do not succeed in escaping the cycle of hunger, eating attacks and countermeasures such as vomiting on their own. Many are ashamed of their behavior. It takes a lot of courage to stand by the disease and seek professional help.

If there is a suspicion that someone in the immediate vicinity (partner, friend or relative) suffers from bulimia, particular sensitivity is required. Confidants should try to bring up the topic - not in front of the assembled family, of course, but in private at a suitable opportunity. If you are unsure, you can get support - for example from your family doctor, advice centers or self-help groups.

Diagnostic criteria

Once those affected have taken the important step of providing honest information about their own eating habits, the diagnosis is clear if ...

  • on average, at least one binge eating with very large amounts of food (up to several thousand calories) occurs per week over a period of more than three months,
  • the seizures are accompanied by a feeling of loss of control.
  • attempts are made to get rid of the calories ingested, for example through self-induced vomiting, laxatives, water tablets, dieting, or excessive exercise. Vomiting is the most common form (80 percent),
  • Eating behavior is very restrictive and controlled between binge eating.

Anyone who fears that they will no longer be able to control their own eating behavior should definitely contact a doctor or psychological psychotherapist - even if the symptoms deviate from the pattern described. The first point of contact can be the family doctor, for example. Talking to the doctor will give you clues as to whether you might have an eating disorder. The doctor will refer you to a specialist if necessary.

In addition to the classic disorders of anorexia and bulimia, there are many sufferers with individual symptoms of an eating disorder who do not meet all the criteria for anorexia and bulimia. In these cases, experts speak of an "unspecified" eating disorder.

Physical examination

The doctor will also do a thorough examination of the patient to rule out any physical illness or medication behind the symptoms. For example, thyroid dysfunction or certain psychotropic drugs can sometimes trigger food cravings. Other or accompanying mental illnesses must also be excluded, such as depression, obsessive-compulsive disorder or borderline disorder.

The doctor will also get an impression of whether the bulimia could have already led to consequential damage and deficiency symptoms - such as dental problems, inflammation of the esophageal mucous membrane, and menstrual disorders.

Blood test

Blood tests show whether there are mineral disorders (electrolyte disorders).

Therapy: how is bulimia treated?

If those affected decide to get professional help, one of the most important steps has already been taken.

Bulimia requires special therapy. Ideally, this consists of a combination of various psychotherapies and other measures (integrated therapy approach).

Depending on the severity of the illness and the accompanying circumstances, treatment can take place in a specialized clinic (inpatient) or on an outpatient basis in a practice. The combination is often chosen: first inpatient, then outpatient.

Therapy modules complement each other

Various specialists usually work together in the treatment of bulimia: for example, medical professionals, psychotherapists, psychologists, nutritionists, music and art therapists. The treatment can take place in group and individual therapy and include, for example, creative procedures, art therapy and body image therapy, movement therapy and group training of social skills. In clinics, therapeutic eating accompaniment and a teaching kitchen complement the treatment concept.

First of all, it is important to compensate for underweight and deficiency symptoms, if any. Nutritional advice, meal plans and meal logs are intended to help those affected find their way back to normal eating behavior. Under supervision, you practice paying closer attention to your body's signals.

With the help of various psychotherapeutic methods, patients also learn to cope better with stress, fear and problems in their everyday life and to gain more self-confidence. They train to be more aware of their feelings and to recognize problematic thought patterns ("I can't do anything", "I have to please everyone"). It is also important to strengthen the self-esteem of those affected.

In most cases it makes sense to involve family members in therapy in order to uncover and resolve conflicts within the family. Finally, sociotherapy helps those affected to cope with their normal everyday life - for example, to adhere to a structured daily routine with fixed meal times, to revive contacts and relationships.

Medicines such as antidepressants can be used as support when psychotherapy does not help enough or when a stressful depressive mood can be detected at the same time. Only the serotonin reuptake inhibitor fluoxetine is approved for bulimia.

It is crucial for the success of a therapy that the patients themselves are motivated to give their life a different direction, that they have freely and consciously decided on treatment. If there is no inner willingness to really leave the disease behind, a successful treatment is difficult to achieve.

Consulting expert

Professor Dr. Ulrich Voderholzer is the Medical Director of the Medical-Psychosomatic Clinic Roseneck in Prien am Chiemsee and an expert on obsessive-compulsive disorders, sleep disorders and depression.


Federal Center for Health Education, Online: (Access: April 2021)

S3 guideline for the diagnosis and treatment of eating disorders, 2018

Important NOTE:

This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.