Skip to main content

What Keeps Bulimia Going?

The “What Keeps It Going?” series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, they provide an easy way for clients to understand at a glance why their disorders persist, and how they might be interrupted. What Keeps Bulimia Going? is designed to help clients experiencing bulimia nervosa understand more about their condition.

Information handouts

Languages available

  • Chinese (Simplified)
  • English (GB)
  • English (US)
  • Polish
  • Spanish (International)

Download or send

Choose your language

Professional version

A PDF of the resource, theoretical background, suggested therapist questions and prompts.

Client version

A PDF of the resource plus client-friendly instructions where appropriate.

Editable version (PPT)

An editable Microsoft PowerPoint version of the resource.

Translation Template

Are you a qualified therapist who would like to help with our translation project?


Many people go through periods where they eat more or less than usual. If these episodes are extreme, distressing, or happen often, they may be a sign of bulimia nervosa. Bulimia can cause a wide spectrum of experiences which include:

  • Binge eating: episodes when your eating feels out of control, excessive, and difficult to stop.
  • Using compensatory behaviors to avoid gaining weight, such as vomiting, restricting what you eat, doing heavy exercise, or taking laxatives or diet pills.
  • Worrying about your weight or how you look.
  • Spending a lot of time and energy in activities related to your weight or eating: such as calorie counting, checking your weight often, using mirrors excessively or avoiding them altogether.
  • Being concerned about your shape, weight, or eating to the extent that it stops you from doing things or gets in the way of your life.

Research studies have shown that cognitive behavioral therapy (CBT) is a helpful psychological therapy for bulimia. CBT therapists work a bit like firefighters: while the fire is burning they’re not so interested in what caused it, but are more focused on what is keeping it going, and what they can do to put it out. This is because if they can work out what keeps a problem going, they can treat the problem by ‘removing the fuel’ and interrupting this maintaining cycle. 


Studies suggest that bulimia is often maintained by several different factors. The What Keeps Bulimia Going? information handout describes some of the key parts which maintain bulimia. It illustrates them in a vicious flower format in which each ‘petal’ represents a separate maintenance cycle. Helping clients to understand more about these processes is an essential part of cognitive therapy for bulimia. Therapists can use this handout as a focus for discussion, or as a template from which to formulate an idiosyncratic model of a client’s experiences.


One interesting way of thinking about bulimia is to look at why, for some people, it does not get better by itself. This handout shows some of the most common reasons why some people keep experiencing symptoms of bulimia. I wonder if we could look at it together and think about whether it describes some of what is happening for you?


  • Slade, E., Keeney, E., Mavranezouli, I., Dias, S., Fou, L., Stockton, S., Saxon, L., Waller, G., Turner, H., Serpell, L., Fairburn, C. G., & Kendall, T. (2018). Treatments for bulimia nervosa: A network meta-analysis. Psychological Medicine, 48, 2629-2636.
  • van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 34, 515-524.