Bulimia nervosa is a serious disorder that involves a recurring pattern of binge eating followed by dangerous compensatory behaviors in an effort to counteract or “undo” the calories consumed during the binge. People with bulimia often feel trapped in this cycle of dysregulated eating, and there is a risk for major medical consequences associated with bulimic behaviors. Research has provided varying results but conservative estimates regarding bulimia indicate that about 1.5% of women and .5% of men will have bulimia at some point in their lifetime. In certain populations, prevalence rates are much higher, such as on college campuses where up to 20% of college-age females endorse symptoms of bulimia.
Diagnostic criteria for Bulimia Nervosa (from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V)
- Recurrent episodes of binge eating
- Recurrent inappropriate compensatory behaviors (such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise) in order to prevent weight gain
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least 1x/week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa
What is a binge?
Many people overeat on occasion – mild or occasional overeating does not constitute a binge. A binge is defined as eating an amount of food, that is definitely larger than most would eat, within a relatively short amount of time, usually considered to be a span of 2 hours or less. However, the defining characteristic of a binge is that the individual experiences a sense of lack of control, and they generally feel powerless over how much or what type of food they are eating. During a binge episode, a person may want to stop eating but feels unable to do so despite physical discomfort and other negative consequences of the binge.
The truth about purging
In addition to physical discomfort, individuals with bulimia typically feel very anxious or shameful after the binge. In their attempt to prevent weight gain and relieve this discomfort they engage in harmful compensatory behaviors. This may include purging behaviors such as self-induced vomiting and misuse of laxatives, diuretics, or other medications. It is very important to know that these actions are not only dangerous, but ineffective. Purging will not aid in weight loss and will most likely contribute to weight gain over the long-term. Individuals with bulimia are usually of normal weight or are slightly overweight. Bulimia may include other non-purging compensatory behaviors such as periods of fasting or excessive exercise.
Signs & Symptoms of Bulimia Nervosa
According to NEDA, Only 6% of people with bulimia receive treatment for their disorder. One reason these numbers are so low is because it often goes unidentified. It’s important to know what behaviors to look for that might suggest someone is suffering. Below is a list of some common warning signs and red flags that might indicate you or a loved one have bulimia nervosa.
Weight & Shape Concerns – Early on in the disorder, it may become apparent that an individual’s self-worth is becoming increasingly dependent upon weight, shape and feedback about their bodies. Thus, efforts to lose weight or change how they look become more intense and you may notice some of the following behaviors:
- Preoccupation with weight and body shape
- Dramatic weight fluctuations up or down
- Frequently or excessively weighing oneself
- Changes in weight, even slight fluctuations, have a significant impact on mood and self-evaluation
- Negative and self-critical comments about one’s body/weight
- Excessive exercise – adhering to a rigid exercise regimen – often accompanying periods of fasting to counteract or “prepare” for binge episodes. This behavior is sometimes referred to as “exercise bulimia”
Food & Eating Behaviors – Most bulimics go through a period of prolonged dieting or restricted eating before the cyclic binging-purging episodes ever begin. The diet mentality causes intense cravings that can set people up to binge and intensifies emotional connections to food and weight. This can be a major trigger for people who are already at-risk for an eating disorder. Common signs and symptoms of bulimia related to food and eating include:
- Evidence of binge eating, including disappearance of large amounts of food in short periods of time or the existence of wrappers and containers indicating the consumption of large amounts of food.
- Eating until the point of discomfort or pain
- Frequent trips to the bathroom immediately after meals
- Any consistent signs or smells of vomiting
- The presence of wrappers/packages of laxatives, diuretics, enemas
- Fasting, dieting, restricting or otherwise limiting food intake for a specified amount of time, followed by increased eating/binging
- Avoiding mealtimes or social situations involving food for fear of losing control/bingeing in a public setting
- Eating alone or in secret
- Hiding or hoarding food
Changes in Personality and Social Behavior – the binge /purge cycle can significantly impact an individual’s daily life as their primary focus becomes increasingly centered on accommodating the disorder. Inconsistent meals, nutritional deficiencies and drastic fluctuations in eating can also impact a person’s mood and behavior.
- Changing lifestyle, daily schedules or establishing rituals to make time for binge-and-purge sessions (Ex: repeatedly skipping a class after lunch or frequently leaving events right after the meal is served)
- Withdrawal from usual friends and activities
- In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns
- Symptoms of depression and anxiety (this can be a sign of an underlying co-occurring disorder )
- Irritability or fluctuating moods
- Substance Abuse
- Signs of self-injury
- Lying about food or making up excuses to try to hide behaviors
- Interpersonal conflicts
- Defensive stance when confronted about weight or eating behaviors
- Low energy and fatigue
Unlike with anorexia, individuals with bulimia often realize that they have a problem and may feel very embarrassed or ashamed about their behavior. These feelings can fuel a cycle of self-criticism and the individual continues to turn to binging/purging as a way of coping with difficult emotions and low self-esteem. An important part of successful treatment for bulimia involves helping the individual interrupt the binge/purge cycle so that they can begin to develop new coping skills and establish a healthy relationship with food and their body.
Health Consequences & Medical Complications of Bulimia Nervosa
In addition to the signs and symptoms of bulimia that are listed above, you may also notice significant changes in health and physical functioning including tooth decay, swollen glands and constipation. In fact, the recurrent binge-and-purge cycles of bulimia can affect the entire digestive system. Bulimic behaviors can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions. While more common than anorexia, bulimia nervosa may be more difficult for primary care physicians, school officials, parents and other loved ones to detect because patients are often of normal weight and may not disclose their abnormal eating behaviors. Some of the health consequences of bulimia nervosa include:
- Severe dehydration and electrolyte imbalances (dangerous levels of sodium, calcium, potassium and other minerals). This can lead to irregular heartbeats, possible heart failure and death.
- Chronically inflamed and sore throat
- Inflammation and possible rupture of the esophagus
- Potential for gastric rupture
- Decalcification of teeth, enamel loss, staining, severe tooth decay and gum disease as a result of repeated exposure to stomach acid
- Edema (swelling)
- Chronic irregular bowel movements, constipation and other gastrointestinal problems
- Peptic ulcers and pancreatitis
- Swollen, enlarged salivary glands in the neck and jaw area
- Acid reflux disorder
- Infertility, increased rates of miscarriage and other fetal complications