Bundesverband der Angehörigen psychisch erkrankter Menschen e.V.

Eating disorders: Bulimia nervosa

Eating disorders are abnormalities in eating behaviour, which occur mainly in adolescent girls and young women in puberty. They are some of the most common chronic health problems in childhood and adolescence. Young men, pre-pubescent children and older women are more rarely affected.

Eating disorders are psychosomatic disorders. This means that they affect both the body and the mind. They are conditions of an addictive nature which can often take a severe course. They can present in “classic” form as anorexia, bulimia or binge eating disorder. But there are also mixed forms and it is often difficult in practice to make a clear distinction since some symptoms are similar. In the course of the condition one form can also merge into another. There are disorders which do not fulfil all the characteristics of anorexia or bulimia. This group of “non-typical” eating disorders occurs frequently in practice.  One thing that all eating disorders have in common is: the sufferer’s thoughts revolve constantly around eating or not eating and their figure. Their whole daily routine is organised around this. Simply eating is no longer possible. Eventually the eating disorder governs their whole lives. It destroys feelings, satisfaction, desire, enjoyment and relationships. It damages health and can be life-threatening. That’s why eating disorders must be treated.

People with bulimia appear very well groomed, are generally slim and athletic, and, if anything, slightly underweight. They are often performance-oriented with a tendency to perfectionism. In public their eating is controlled; their binge attacks happen in secret. Sufferers associate these binge attacks with strong feelings of shame and anxiety; they are disgusted with themselves and hate their bodies.

The struggle with food (excessive consumption of food or refusal to eat) can be seen as a substitute for deeper psychological conflicts. The altered eating behaviour represents an attempt to find a solution. It serves as an escape or flight from suppressed needs and unpleasant feelings like stress, fear, despair and loneliness. Eating or starving themselves serves to temporarily dispel their inner tension. A feeling of safety and satisfaction is experienced. In order to maintain this feeling, the behaviour must be repeated. This causes the eating disorder to gain momentum with negative physical and psychological consequences.

Characteristics of bulimia

Please note that the characteristics below can only be indications of bulimia and do not necessarily all occur at the same time; diagnosis can only be made by specialists

Body weight:

  • Normal weight, slightly underweight
  • Pathological fear of getting fat

Control of body weight:

  • Binge attacks alternate with fasting days
  • Forced vomiting, use of laxatives, diuretic tablets or enemas
  • Excessive checking of weight
  • Extreme physical activity: the self-imposed exercise regime is then an absolute must that cannot be missed.

Eating behaviour:

  • Controlled eating in public
  • Secret binges, where large quantities of food are consumed in a short time
  • Withdrawal after mealtimes
  • Stockpiling of food; unexplained disappearance of food
  • Excessive or secret taking of mineral water (helps with vomiting)

Social behaviour:

  • Low self-esteem
  • Extreme performance orientation, perfectionism
  • Significant increase or drop in performance
  • Withdrawal from family, friends
  • Neglect of hobbies
  • Denial of problems
  • In some sufferers:
    Impulsive actions with loss of control e.g. shoplifting, abuse of alcohol, pharmaceuticals, drugs, uncontrolled spending, self-harm

Physical symptoms:

  • Frequent stomach pain
  • Swelling of the salivary glands ("hamster cheeks")
  • Grazes on fingers or the backs of the hands (triggering the gag reflex also activates the bite reflex)
  • Possible stopping of periods

Risk factors

Experts believe that the development of bulimia stems from the interaction of certain biological, socio-cultural and psychological factors, the significance of which is however seen differently in the various models. Risk factors include, e.g.:

Biological/genetic factors:

  • Genetic disposition
  • Complications in pregnancy and childbirth

Behaviour learned in social environment:

  • Attitudes to food, diets, evaluation of weight and figure
  • Attitudes to conflict, achievement, expectations
  • Experience of emotional neglect or physical violence

Temperament and personality:

  • Prior anorexia
  • Low self-esteem, fear of failure, strong need for harmony
  • Fear of loss and separation  
  • Suppression of feelings and needs

Social factors:

  • Beauty ideals
  • Changing expectations of role

Consequences of bulimia

The severity of the consequences of bulimia depends on the number of binges. Up to 1% of sufferers die from the disease.

Physical consequences

The abnormal eating behaviour can affect the whole metabolism and all the organs. Particularly common effects are: damage to teeth, throat and oesophagus, electrolyte deficiencies, cardiac and vascular effects, impaired renal function, hormone imbalance, stomach and intestinal complaints, impaired perception of hunger and fullness


Psychological consequences

Obsessive-compulsive disorders, anxiety and depression often occur alongside bulimia; if these conditions were already present before the development of bulimia, this can further their intensify symptoms. In addition in the course of the condition the sufferer comes to devalue themselves more and more and may even come to hate themselves.

Missed puberty

In puberty there is a move towards adult life. Adolescents with bulimia miss this phase and thus important development steps.


Self-harming can be a consequence of bulimia, but occurs more often without an eating disorder.

Social behaviour

In a severe progression there may be abnormalities in social behaviour. Sufferers are often moody, impulsive or aggressive; their behaviour is contradictory. They may steal food or money, or get into debt to be able to buy food for their binge attacks.


Just as the consequences of bulimia depend on the severity of the condition, so too does the appropriate treatment. In mild cases outpatient treatment may be sufficient, in more severe cases hospital admission or part-time residential care may be necessary. A therapeutic living community can also help. In the case of children and adolescents, parents are usually involved in the treatment.

It can be months or years before full recovery is made from an eating disorder. So it is important that all those involved don’t lose hope or courage.

Each therapy consists of several supplementary components (integrative or multimodal approach). These components include:

Advice centre for eating disorders (drop-in, telephone, Internet)

Evaluation of the situation, provision of information, motivation to treatment


The main focus of treatment for eating disorders. This uses mainly two procedures, the costs of which are reimbursed by health insurers: cognitive behavioural therapy and depth psychological psychotherapy. In addition there is also psychoanalysis, interpersonal psychotherapy and systemic family therapy. You should find out in advance the extent to which your health insurer will assume these costs. Depending on the specific situation either individual or group therapy is used.

Medical treatment

Monitoring of weight changes, treatment of accompanying physical conditions

Supportive nutritional therapy

Nutritional advice specifically tailored to eating disorders

Supplementary therapies

Relaxation, body awareness, dance, design, music or art therapy

Self help

Self-help programmes for those affected can support treatment, but never replace it. Self-help for relatives offers the opportunity to talk to other parents or relatives.

After care

Confirmation of treatment success; avoidance of relapses

Tips for parents and other relatives

  • If you suspect your child might be anorexic don’t close your eyes to it. This disease makes many parents feel helpless. Remind yourself that eating disorders are psychosomatic conditions with addictive nature and find out all you can about the disorder (leaflets, advice centres).
  • An eating disorder doesn’t just affect the child suffering from the condition but rather the whole family structure. Apportioning blame upon the other partner and the child is not helpful. Try instead to find ways out of the situation and support the child. If at all possible do not make decisions over his or her head.
  • Speak about the problem openly; don’t dramatise it, but don’t play it down either; try to stay calm. Talk about your fears without apportioning blame and concentrate on changes in the child’s behaviour. The child will probably deny the problems, perhaps also react aggressively or seek to explain away their changed behaviour. This is typical for eating disorders. Don’t let yourself be fobbed off or shut out.
  • Insist on a visit to the doctor and encourage approaching an advice centre. But be aware that you will need lots of patience, even constant reasoning will often not help for a long time. The person affected must decide for themselves when to ask for help.
  • In severe cases bulimia can be life-threatening. If you fear such a situation, go to a doctor immediately or have your child admitted to a clinic, if necessary against their will – this can save your child’s life.
  • The same applies if you have (hidden) indications that the child is harbouring thoughts of suicide or even has attempted suicide in the past. Don’t hesitate to get help. Remember that admission to a clinic (child psychiatric or psychosomatic clinic) can only be ordered by a doctor.
  • In crisis situations you can also contact the “Sozialpsychiatrischer Dienst” (social psychiatric service) which is available in every town or district. It may be helpful to keep the phone number handy for emergencies.
  • Accept that you cannot treat your child’s illness. Leave therapy to the experts (doctor, psychotherapist). Keep yourself informed as to the nature and goals of treatment. If you support the treatment that can be a valuable help.
  • Agree rules for joint mealtimes; such conversations are often best handled in the presence of a neutral third party.
  • Despite your worry, try not to allow your child’s eating disorder to dominate family life. Allow yourself time off to recharge your batteries and don’t forget that your partner and other children have their own needs. Give them your attention and time.
  • Despite your worry, try not to allow your child’s eating disorder to dominate family life. Allow yourself time off to recharge your batteries and don’t forget that your partner and other children in the household have their own needs. Give them your attention and time.

Further Information The largest German language self-help group for people with eating disorders and their relatives; information, forum, chat Federal Centre for Health Education; leaflets, advice line (also available on Saturday and Sunday), advice centre addresses Federal Association of Child and Adolescent Helplines; telephone and e-mail advice for children and adolescents from professional advisors or adolescents for other adolescents; telephone helpline for parents. a wide range of advisory services by the Federal Conference for Parent Counselling for parents and young people, addresses of advice centres, moderated forum, chats.

Beware of the websites Pro Ana and Pro Mia! Pages like these contain advice for persons affected on how to keep losing weight, hide their weight loss or avoid therapy.