Anorexia and Bulimia
well-researched information for the public
For anyone who is
worried about themselves, a friend or a relative.
Health: have you been affected by the recession? We
would welcome your views.
About this leaflet
We hope that this leaflet will be helpful if:
- you are constantly thinking with your weight and body
- you feel that your eating or dieting may be a problem
- you find yourself obsessively using other ways to lose weight,
such as over-exercising or making yourself sick
- you think you might have anorexia or bulimia
- other people worry that you have lost too much weight
- you have a friend or relative, son or daughter, who is having a
problem of this sort.
It does not deal with the problems of being overweight.
We all have different eating habits. There are a large number
of “eating styles” which can allow us to stay healthy. However,
there are some which are driven by an intense fear of becoming fat
and which actually damage our health. These are called “eating
disorders” and involve:
- eating too much
- eating too little
- using harmful ways to get rid of calories.
In fact, the 'eating disorders' usually involve a lot more than
eating behaviour, so that people affected by them are constantly
worrying about how to avoid taking in calories or how to 'burn off'
or how to get rid of them. They also find themselves checking their
weight and appearance all the time to reassure
themselves that their weight has not increased.
This leaflet deals with two eating disorders - Anorexia Nervosa
and Bulimia Nervosa. It describes the two disorders separately,
- the symptoms of anorexia and bulimia are often mixed
- people may also move from bulimia to anorexic, or you
may start with anorexic symptoms, but later develop the symptoms of
Who gets eating disorders?
Girls and women are 10 times more likely than boys and men to
suffer from anorexia or bulimia. However, eating disorders do seem
to be getting more common in boys and men - they are more
likely to develop their disorder in association with over-exercise
and to want to be of a muscular build rather than a very skinny
What are the signs?
You find that you:
- worry more and more about your weight
- eat less and less
- exercise more and more, to burn off calories
- can't stop losing weight, even when you are well below a safe
weight for your age and height
- smoke more or chew gum to keep your weight down
- obsessively check your weight, shape or reflection in
- withdraw from social situations which may involve eating
- lose interest in sex
- In girls or women - monthly menstrual periods become irregular
- In men or boys - erections and wet dreams stop, testicles
Some people notice that they have developed other obsessive
difficulties, such as having to stick to rigid routines and times,
or perhaps fears of 'contamination', a need to study or work all
the time, or difficulty in spending money appropriately.
When does it start?
We now know that people of any age
can have anorexia, but it commonly starts in the teenage
years. It affects around:
- 1 fifteen-year-old girl in every 150
- 1 fifteen-year-old boy in every 1000.
- You take in very few calories every day. You eat "healthily" -
fruit, vegetables and salads - but they don't give your body enough
- You may also exercise, use slimming pills, or smoke more to
keep your weight down.
- You don't want to eat yourself, but you buy food and cook for
- You still get as hungry as ever, in fact you find
you can't stop thinking about food.
- You become more afraid of putting on weight, and more
determined to keep your weight well below what is normal.
- Your family may be the first to notice your thinness and weight
- You may find yourself lying to other people about the amount
you are eating and how much weight you are losing.
- You may also make your self sick if you eat anything you did
not plan to allow yourself, particularly if you lose control of
your eating and find yourself bingeing. However, this is known as
'anorexia, binge-purge subtype' rather than bulimia nervosa.
Bulimia nervosa sufferers are by definition in the normal weight
What are the signs?
You find that you:
- worry more and more about your weight
- binge eat (see below)
- make yourself vomit and/or use laxatives or other ways to
get rid of calories
- have irregular menstrual periods
- feel tired
- feel guilty
- stay a normal weight, in spite of your efforts to diet.
When does it start?
Bulimia Nervosa often starts in the mid-teens. However, people
don't usually seek help for it until their early to mid-twenties
because they are able to hide it, even though it affects their work
and social life. People most often seek help when their life
changes - the start of a new relationship or having to live with
other people for the first time.
About 4 out of every 100 women suffers from bulimia at some time
in their lives, rather fewer men.
You raid the fridge or go out and buy lots of fattening foods
that you would normally avoid. You then eat it all, quickly,
usually in secret. You might get through packets of biscuits,
several boxes of chocolates and a number of cakes in just a couple
of hours. You may even take someone else’s food, or shoplift, to
satisfy the urge to binge. Binges may begin as a planned meal, but
because you have been restricting what you eat, you find that a
normal meal doesn't satisfy you so that you can't stop
Afterwards you feel stuffed and bloated – and probably guilty
and depressed. You try to get rid of the food you have eaten by
making yourself sick, or by purging with laxatives. It is very
uncomfortable and tiring, but you find yourself trapped in a
routine of binge eating, and vomiting and/or purging.
Binge Eating Disorder
This is a pattern of behaviour that has recently been
recognised. It involves dieting and binge eating, but not vomiting.
It is distressing, but much less harmful than bulimia, and usually
more responsive to therapy. Sufferers are more likely to become
How can anorexia and bulimia affect you?
If you aren't getting enough calories, you may:
- Sleep badly.
- Find it difficult to concentrate or think clearly about
anything other than food or calories.
- Feel depressed.
- Lose interest in other people.
- Become obsessive about food and eating (and sometimes other
things such as washing, cleaning or tidiness).
- Find it harder to eat because your stomach has shrunk.
- Feel tired, weak and cold as your body's metabolism slows
- Become constipated.
- Notice changes in your hair and skin. Some people's head hair
falls out, but they grow downy hair on other parts of the body.
Skin becomes dry and you can have pressure sores.
- Not grow to your full height, or lose height with a 'bowed
- Get brittle bones which break easily.
- Be unable to get pregnant.
- Damage your liver, particularly if you drink alcohol.
- In extreme cases, you may die. Anorexia Nervosa has the highest
death rate of any psychological disorder.
If you vomit, you may:
- lose the enamel on your teeth (it is dissolved by the stomach
acid in your vomit)
- get a puffy face (the salivary glands in your cheeks swell
- notice your heart beating irregularly - palpitations (vomiting
disturbs the balance of salts in your blood)
- feel weak
- feel tired all the time
- experience huge weight swings (see below)
- damage your kidneys
- have epileptic fits
- be unable to get pregnant.
If you use a lot of laxatives, you may:
- have persistent stomach pain
- get swollen fingers
- find that you can't go to the toilet any more without using
laxatives (using laxatives all the time can damage the muscles in
- have huge weight swings. You lose lots of fluid when you purge,
but take it all in again when you drink water afterwards (no
calories are lost using laxatives).
What causes eating disorders?
There is no simple answer, but these ideas have all been
suggested as explanations:
- Social pressure: Our social surroundings
powerfully influence our behaviour. Societies which don’t value
thinness have fewer eating disorders. Places where thinness is
valued, such as ballet schools, have more eating disorders. ‘Thin
is beautiful’ in Western culture. Television, newspapers and
magazines show pictures of idealised, artificially slim people. So,
at some time or other, most of us try to diet. Some of us diet too
much, and may develop anorexia.
- Lack of an “off” switch: Most of us can only
diet so much before our
body tells us that it is time to start eating again. Some people
with anorexia may not have this same body "switch" and can keep
their body weight dangerously low for a long time.
- Control: It can be very satisfying to diet.
Most of us know the feeling of achievement when the scales tell us
that we have lost a couple of pounds. It is good to feel that we
can control ourselves in a clear, visible way. It may be that your
weight is the only part of your life over which you feel you do
have any control.
- Puberty: Anorexia can reverse some of the
physical changes of becoming an adult – pubic and facial hair in
men, breasts and menstrual periods in women. This may help to put
off the demands of getting older, particularly sexual ones.
- Family: Eating is an important part of our
lives with other people. Accepting food gives pleasure and refusing
it will often upset someone. This is particularly true within
families. Saying “no” to food may be the only way you feel
you can express your feelings, or have any say in family
affairs. On the other hand, loving families often try to protect
you from the consequences of an eating disorder, and this can mean
that the eating disorder can go on longer.
- Genetics: There is a lot of evidence that
eating disorders run in families even where the sufferers don't
necessarily live together, and that certain genes make people more
vulnerable, not only to eating disorders, but to related
- Depression: Most of us have eaten for comfort
when we have been upset, or even just bored. People with bulimia
are often depressed, and it may be that binges start off as a way
of coping with feelings of unhappiness. Unfortunately, vomiting and
using laxatives can leave you feeling just as bad.
- Low self-esteem: People with anorexia and
bulimia often don’t think much of themselves, and compare
themselves unfavourably to other people. Losing weight can be a way
of trying to get a sense of respect and self-worth.
- Emotional distress: We all react
differently when bad things happen, or when our lives change.
Anorexia and bulimia have been related to:
- life difficulties
- sexual abuse
- physical illness
- upsetting events - a death or the break-up of a
- important events - marriage or leaving home.
- The vicious circle : An eating disorder
can continue even when the original stress or reason for it has
passed. Once your stomach has shrunk, it can feel uncomfortable and
frightening to eat.
- Physical causes: Some doctors think that
there may be a physical cause that we don't yet
- Certain illnesses and treatments: There is a
relatively high incidence of anorexia in people who suffer from
diabetes, Cystic Fibrosis or other illness where diet has to be
monitored and without adequate treatment, weight is lost. It can be
tempting to neglect your health in order to lose some weight, and
this is particularly dangerous.
Is it different for men?
- Eating disorders do seem to have become more common in boys and
- Eating disorders are more common in occupations which demand a
low body weight (or low body fat). These include horse
riding, body building, wrestling, dancing, swimming, and
- It seems that gay men and boys are more likely to suffer from
- It may be that men are now seeking help for eating disorders
rather than keeping quiet about them.
People with special needs and younger
A learning difficulty, autism or some other developmental
problems can disrupt eating. For example, some people with autism
may take a dislike to the colour or texture of foods, and refuse to
eat them. The eating problems of pre-teen children are more to do
with food texture, “picky eating” or being angry rather than with
wanting to be very thin. The ways of helping these problems are
rather different from those for anorexia and bulimia.
Do I have a problem?
The 'SCOFF' questionnaire used by doctors asks:
- do you make yourself Sick because you're
- do you worry that you’ve lost Control over how
much you eat?
- have you recently lost more than 6 kilograms
(about One stone) in three months?
- do you believe you’re Fat when others say
- would you say that Food dominates your
If you answer “yes” to two or more of these questions, you may
have an eating disorder.
- Bulimia can sometimes be tackled using a self-help manual with
some guidance from a therapist.
- Anorexia usually needs more organised help from a clinic or
therapist. It is still worth getting as much information as you can
about the options, so that you can make the best choices for
- Stick to regular mealtimes – breakfast, lunch and dinner. If
your weight is very low, have morning, afternoon and night time
- Try to think of one small step you could take towards a
healthier way of eating. If you can’t face eating breakfast, try
sitting at the table for a few minutes at breakfast time and just
drinking a glass of water. When you have got used to doing this,
have just a little to eat, even half a slice of toast – but do it
- Keep a diary of what you eat, when you eat it and what your
thoughts and feelings have been every day. You can use this to see
if there are connections between how you feel, what you are
thinking about, and how you eat.
- Try to be honest about what you are or are not eating, both
with yourself and with other people. Secrecy is one of the most
isolating aspects of an eating disorder.
- Remind yourself that you don’t always have to be achieving
things – let yourself off the hook sometimes.
- Remind yourself that, if you lose more weight, you will feel
more anxious and depressed in the medium-term, even though you may
feel better short-term.
- Make two lists – one of what your eating disorder has given
you, one of what you have lost through it. A self-help book can
help you with this.
- Try to be kind to your body, don’t punish it.
- Make sure you know what a reasonable weight is for you, and
that you understand why.
- Read stories of other people’s experiences of recovery. You can
find these in self-help books or on the internet.
- Think about joining a self-help group. Your GP may be able to
recommend one, or you can contact the Eating Disorders Association
(see page 22).
- Avoid websites or social networks that encourage you to
lose weight and stay at a very low body weight. They encourage you
to damage your health, but won’t do anything to help when you fall
- Don’t weigh yourself more than once a week.
- Don’t spend time checking your body and looking at yourself in
the mirror. Nobody is perfect. The longer you look at yourself, the
more likely you are to find something you don’t like. Constant
checking can make the most attractive person unhappy with the way
- Don’t cut yourself off from family and friends. You may want to
because they think you are too thin, but they could be a
What if I don’t have any help or don’t change my eating
Most people with a serious eating disorder will end up having
some sort of treatment, so it is not clear what will happen if
nothing is done. However, it looks as though most serious eating
disorders don’t get better on their own. Some sufferers from
anorexia will die – this is less likely to happen if you do not
vomit, do not use laxatives and do not drink alcohol. Exercise at
low weight is dangerous, particularly if you exercise outdoors in
- Your GP can refer you to a specialist counsellor, psychiatrist
- You may choose a private therapist, self-help group or clinic,
but it is still safer to let your GP know what is happening.
- It's wise to have a good physical health check. Your eating
disorder may have caused physical problems. Less commonly, you may
have an unrecognised medical condition.
- The most helpful treatments for you will probably depend on
your particular symptoms, your age and situation.
- A psychiatrist or psychologist will first want to talk with
you, to find out when the problem started and how it developed. You
will be weighed and, depending on how much weight you've lost, may
need a physical examination and blood tests. With your permission,
the psychiatrist will probably want to talk with your family (and
perhaps a friend) to see what light they can shed on the problem.
If you do not want your family involved, even very young patients
have a right to confidentiality. This can sometimes be appropriate
because of abuse or stress in the family.
- If you are still living at home, your parents may get the job
of checking what food you are eating, at least at first. This
involves making sure that you have regular meals with the rest of
the family, and that you get enough calories. You will see a
therapist regularly, both to check your weight and for
- Dealing with this can be stressful for everyone concerned, so
your family may need support. This doesn't necessarily mean that
the whole family has to come to therapy sessions together (although
this can be helpful for younger people). It does mean that your
family can get help to understand and cope with the problem.
- You will have the chance to discuss anything that may be
upsetting you - how to get on with the opposite sex,studying, work,
self-consciousness, or any family problems.
- At first, you probably won't want to think about getting back
to a normal weight, but you will want to feel better - and in
order to feel better, you will need to get back to a healthy
weight. You will need to know:
- what is your healthy weight?
- how much food you need each day to get there?
- how can you make sure that you don't become fat?
- how can you be sure that you can control your eating?
Psychotherapy or counselling
- This involves talking with a therapist, perhaps for 1 hour
every week, about your thoughts and feelings. It can help you to
understand how the problem started, and how you can change some of
the ways you think and feel about things. It can be upsetting to
talk about some things, but a good therapist will help you to do
this in a way which helps you to cope better with your
difficulties. They will also help you value yourself more, and
rebuild your self-esteem.
- Specially focussed versions of Cognitive Behavioural Therapy and Interpersonal Therapy are often offered,
once you are well enough to benefit from the challenges of therapy
rather than be more stressed by them. If you have therapy while
your weight is low or falling, it appears that stress can make
things worse rather than better.
- Sometimes it can be done in a small group of people with
- Other members of your family can be included with your
permission. The best researched form of family therapy for
anorexia is known as the 'Maudsley Model'. Adults who have a
partner may be treated as a couple. Relatives and carers may
also be seen separately for sessions to help them understand what
has happened to you, how they can work together with you, and how
they can cope with the situation.
- Treatment of this sort can last for months or years.
- The doctor will only suggest admission to hospital if these
steps do not work, or if you are dangerously underweight.
This also involves controlling your eating and talking about
problems, only in a more supervised and structured way.
- Blood tests will be done to check whether you are anaemic or at
risk of infection.
- Regular weight checks - to make sure that you are slowly
- Other physical investigations may be needed to monitor any
damage to your heart, lungs and bones.
Advice and help with eating
- A dietician may meet with you to discuss healthy eating - how
much you eat and how to make sure you get all the nutrients you
need to stay healthy.
- You may need vitamin and mineral supplements for a while
as your body may lack essential nutrients.
- You can only get back to a healthy weight by eating more and
this may be very difficult at first. Staff will help you to:
- set reasonable targets for gaining weight
- eat regularly
- cope with the anxiety you feel.
Doctors sometimes prescribe medication to help reduce the
anxiety you experience while tackling the illness and, in
particular, to reduce the 'ruminations' that sufferers describe.
Most experience has been with the drug Olanzapine, as this is
safest in young people and in people who are at a
low weight. It may be more effective than diazepam and similar
drugs and is less likely to be habit-forming.
Gaining weight is not the same thing as recovery - but you can't
recover without gaining weight. People who are severely starved
usually find it difficult to concentrate or think clearly,
particularly about their feelings.
This is unusual. It is only done if someone has become so unwell
that he or she:
- cannot make proper decisions for themselves
- needs to be protected from serious harm.
In anorexia, this may happen if your weight is so low that your
health (or life) is in danger and your thinking has been severely
affected by the weight loss.
How effective is the treatment?
- More than half of sufferers make a recovery, although they will
on average, be ill for 6-7 years.
- Full recovery can happen even after 20 years of severe
- Past studies of the most severely-ill people admitted to
hospital have suggested that 1 in 5 of these may die. With
up-to-date care, the death rate is much lower, if the person stays
in touch with medical care.
- As long as the heart and other organs have not been damaged,
most of the complications of starvation seem to improve slowly once
a person is eating enough.
Two kinds of psychotherapy
have been shown to be effective in Bulimia Nervosa. They are both
given in weekly sessions over about 20 weeks.
Cognitive Behavioural Therapy (CBT)
This is usually done with an individual therapist, with a self-help
book, in group sessions, or with a CD Rom. CBT helps you to look at
your thoughts and feelings in detail. You may need to keep a diary
of your eating habits to help find out what triggers your binges.
You can then work out better ways of thinking about, and dealing
with, these situations or feelings. As with the treatment for
anorexia, the therapist will help you to regain your sense of your
own value as a person.
Interpersonal Therapy (IPT)
This is also usually done with an individual therapist, but
concentrates more on your relationships with other people. You may
have lost a friend, a loved one may have died or you may have been
through a big change in your life, like moving. It will help you to
rebuild supportive relationships that can meet your emotional needs
better than eating.
This helps you to get back to regular eating, so you can maintain a
steady weight without starving or vomiting. A dietician can advise
you on healthy eating. A guide such as
“Getting Better BITE by BITE” (see references) can be helpful.
Even if you are not depressed,
high doses of antidepressants such as Fluoxetine (Prozac) can
reduce the urge to binge eat. This can reduce your symptoms in 2-3
weeks, and provide a “kick start” to psychotherapy. Unfortunately,
without the other forms of help, the benefits wear off after a
How effective is the treatment?
- About half of sufferers recover, cutting their bingeing and
purging by at least half. This is not a complete cure, but will let
you get back some control of your life, with less interference from
the eating problem.
- The outcome is worse if you also have problems with drugs,
alcohol or harming yourself.
- CBT and IPT work just as effectively over a year, although CBT
seems to start to work a bit sooner.
- There is some evidence that a combination of medication and
psychotherapy is more effective than either treatment on its
- Recovery usually takes place slowly over a few months or many
beat (formerly the
Eating Disorders Association)
Helpline: 0845 634 1414 (Mon- Fri, 10:30-8.30pm,
and Saturday 1.00- 4:30pm.
beat youth helpline: 0845 634 7650 (Mon- Fri,
4.00-6.30pm and Saturday: 1.00-4:30 pm.)
beat is an organisation that campaigns, that
challenges the stigma faced by people with eating
disorders and that gives people the help and support they
Bodywhys – The Eating Disorders
Association of Ireland: Helpline: 1890 200 444. Email:
(Diabetics with eating disorders website)
Hope: American website offering information,
eating disorder treatment options, recovery tools and resources to
those suffering from eating disorders, their treatment providers
and loved ones.
Provides help to those who are mentally ill and promotes positive
(Men get eating disorders too): A national charity dedicated to
representing and supporting the needs of men with eating
Tel: 0845 4647 (24hr)
Advice from a nurse on all health topics.
talk: has a section focussing on young people with
Online CBT resources
Breaking free from anorexia nervosa: a survival guide
for families, friends and sufferers by Janet Treasure
Anorexia nervosa and bulimia: how to help by M.
Duker & R. Slade (Open University Press).
Eating Disorders: A parents' guide by Rachel
Bryant-Waugh and Brian Lask (Penguin Books).
Skills-based learning for caring for a loved one with an
Eating Disorder: The New Maudsley Method. Janet Treasure,
Grainne Smith and Anna Crane.
Bulimia Nervosa and Binge eating: A guide to recovery
by P. J. Cooper and Christopher Fairbairn (Constable and
Overcoming binge eating by Christopher Fairburn
Getting better BITE by BITE: A survival kit for sufferers of
bulimia nervosa and binge eating disorders by Janet
Treasure and Ulrike Schmidt (Hove Psychology Press).
Anorexia Nervosa and Related Eating Disorders (ANRED).
Self-help tips: http://www.anred.com/slf_hlp.html
- Agras, W. S.,Walsh, B.T., Fairburn, C. G., et al (2000) A
multicentre comparison of cognitive-behavioural therapy and
interpersonal psychotherapy for bulimia nervosa. Archives of
General Psychiatry, 57, 459-466.
- Bacaltchuk J., Hay P., Trefiglio R. Antidepressants versus
psychological treatments and their combination for bulimia nervosa
(Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford:
- Bissada H. et al. Olanzapine in the treatment of low body
weight and obsessive thinking in women with anorexia nervosa: a
randomized, double-blind, placebo-controlled trial. Am J
Psychiatry 2008 Jun 16.
- Eisler, I., Dare, C., Russell, G. F. M., et al (1997) Family
and individual therapy in anorexia nervosa. Archives of General
Psychiatry, 54, 1025-1030.
- Eisler, I., Dare, C., Hodes, M., et al (2000) Family therapy
for anorexia nervosa in adolescents: the results of a controlled
comparison of two family interventions.
Journal of Child Psychology and Psychiatry, 41,727-736.
- Fairburn, C. G., Norman, P.A., Welch, S. L., et al (1995) A
prospective study of outcome in bulimia nervosa and the long-term
effects of three psychological treatments. Archives of General
Psychiatry, 52, 304-312.
- Hay, P. J., & Bacaltchuk, J. (2001) Psychotherapy for
bulimia nervosa and bingeing (Cochrane Review) In: The Cochrane
Library, Issue 1.
- Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D.L.
& Herzog, W. (2001). Long-term outcome of anorexia nervosa in a
prospective 21-year follow-up study. Psychological Medicine, 31,
- Luck A.J., Morgan J.F., Reid F. et al. (2002) The SCOFF
questionnaire and clinical interview for eating disorders in
general practice: comparative study. BMJ, 325, 755-756.
- Milos, G., Spindler A., Schnyder, U. & Fairburn, C.G.
Instability of eating disorder diagnoses: prospective study.
British Journal of Psychiatry, 187, 573-578.
- Theander, S. (1985) Outcome and prognosis in anorexia nervosa
and bulimia. Some results of previous investigations compared with
those of a Swedish long-term study. Journal of Psychiatric
Research, 19, 493-508.
- Senior R; Barnes J; Emberson J.R. and Golding J. on behalf of
the ALSPAC Study Team (2005) Early experiences and their
relationship to maternal eating disorder symptoms, both lifetime
and during pregnancy. British Journal of Psychiatry, 187,
Produced by the Royal College of Psychiatrists' Public Education
Series Editor: Dr Philip Timms
Expert review: Dr Jane Morris
User & Carer input: Royal College of Psychiatrists' Service
User Recovery Forum
© Illustration by Lo Cole: www.locole.co.uk
This leaflet reflects the best available evidence available at
the time of writing.
© February 2013. Due for review: February 2015. Royal
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