Bulimia Nervosa

What is an Eating Disorder?

An eating disorder is a mental illness that can cause a person to be preoccupied with their weight, food intake, and body shape. As a result, it forms an unhealthy relationship between food and body image.

Eating disorders are more than just about weight loss or gaining weight—they are about how a person feels about themselves and their body.

Bulimia nervosa is one type of eating disorder that involves bingeing and purging. Bulimics use binging (eating large amounts of food at once) and purging (vomiting or using laxatives after eating) to control their weight or prevent weight gain. They may also engage in excessive exercise or fasting to compensate for binging.

Bulimia VS Anorexia Nervosa

Bulimia and anorexia nervosa have a lot of similarities. Both disorders involve a significant distortion of body image, food and weight concerns, and an obsession with dieting.

However, there are some key differences between bulimia and anorexia.

• In bulimia nervosa, the person will binge on food (usually high-calorie foods) and then engage in compensatory behaviors such as purging to prevent weight gain. On the other hand, in anorexia nervosa, the person refuses to eat at all or eats very little food, resulting in severe weight loss (and thus malnutrition).
• People with anorexia nervosa often have a distorted body image (they think they’re fat even though they’re dangerously thin), while those with bulimia often try to maintain their body weight.
• Another way that these two disorders differ is that people with bulimia tend to fluctuate between periods of overeating and purging. In contrast, people with anorexia typically starve themselves but occasionally engage in “binge-purge” behaviors.
• While both disorders can cause severe medical complications, anorexia has a higher mortality rate than bulimia.

Symptoms of Bulimia Nervosa

Bulimia nervosa is a severe mental health condition that affects people physically, mentally, and emotionally.

While these symptoms are not exclusive to bulimia nervosa, they are common among those who suffer from the illness. People who experience them should seek help from a licensed therapist or physician.

• Dental Erosion: The acid from vomiting and repeated exposure to stomach acid can erode tooth enamel, leading to cavities and sensitivity to hot or cold foods and drinks.
• Compromised Salivary Glands: Frequent vomiting can cause the salivary glands in your mouth to become inflamed or swollen, leading to difficulty chewing, swallowing, or speaking.
• Dehydration: Vomiting causes dehydration because it uses up water from the body. Dehydration can lead to dry mouth, dry skin, and low blood pressure, which can be dangerous if left untreated.
• Laxative Abuse: Laxatives, enemas, or diuretics (water pills) are drugs that cause bowel movements to occur. Bulimics use laxatives to purge the body of food and calories. They may take large doses of laxatives or use them repeatedly to get rid of food after a binge.
• Diarrhea: Bulimics sometimes induce diarrhea by taking large amounts of laxatives or diuretics (water pills). As a result, dehydration occurs, further increasing the risk of health complications associated with bulimia nervosa.
• Vomiting: Vomiting is a common symptom of bulimia, and several factors can trigger it:
  • It’s often a response to guilt or shame about eating
  • The physical discomfort of overeating
  • A fear of gaining weight
  • A way to control weight
  • Individuals who force themselves to vomit may have calluses that form on their knuckles.
• Dizziness: Dizziness is another physical symptom of bulimia nervosa resulting from purging behaviors or excessive exercise. The loss of water and nutrients through self-induced vomiting or excessive sweating can lead to dehydration, causing dizziness and fainting spells.
• Frequent Trips to the Bathroom After Meals: Another symptom of bulimia nervosa is frequent bathroom visits after meals. While it is often mistaken for having an upset stomach, it is usually due to repeated purging following large meals.

Mental and Emotional Symptoms of Bulimia

The mental and emotional symptoms of Bulimia Nervosa include:

• A Distorted View of Body Shape and Size: People with bulimia nervosa often believe they are overweight, even when they’re not. They may also think that certain parts of their bodies are too large, even if they’re in the normal range for healthy people.
• Low Self-esteem and Poor Body Image: People with bulimia nervosa don’t feel good about themselves, leading to low self-esteem and poor body image. They may also have difficulty accepting compliments from others because they don’t believe them to be true.
• Extreme Fear of Gaining Weight: Many people with bulimia nervosa fear gaining weight or becoming fat. This fear can lead to drastic measures such as purging after eating just a few bites of food or over-exercising to burn off calories consumed during an episode of bingeing on food.
• Depression and Anxiety: Bulimics may experience depression because they try hiding their binging and purging activities from others. They may also be anxious about how much weight they have lost or gained during their cycle of bingeing and purging.
• Social Isolation: People with this condition tend to isolate themselves from their family members and friends because they are ashamed of their eating disorder. They may also have intense anxiety about eating in public places or around others watching them eat.
• Lacking Self-Control: People with bulimia nervosa often eat large amounts of food quickly, even when they are not hungry. They may also feel like they have no control over their eating habits.
• Guilt Associated With Bingeing and Purging: Feelings of guilt about eating can cause people to purge their bodies of food after a binge, which leads to even more guilt and shame. This cycle can be tough to break because it often becomes a habit, especially if the person has been doing it for a long time.

What Causes Bulimia?

Bulimia is a serious eating disorder that can be dangerous and even life-threatening. If you or a loved one has bulimia, you must understand the causes and risk factors.

Knowing how these factors impact the development of bulimia will help you begin to take steps toward recovery.

Risk Factors of Bulimia

Bulimia affects people of all ages, races, and genders. However, some people are more likely to develop it than others. Risk factors include:

• Family History of Eating Disorders: One risk factor is having a family history of eating disorders. If you have an immediate family member who has had bulimia or another eating disorder, you have a higher chance of developing the disorder than someone without this history.
• Gender: One risk factor is being female. Women are more likely to develop bulimia than men, and this may be because they are more likely to have a negative body perception. They also care more about their physical appearance than men.
• Being Overweight or Obese at an Early Age: Children who become overweight or obese before puberty are more likely than their peers to develop an eating disorder later in life. The emotional toll that weight gain takes on young people, especially during puberty when their bodies change dramatically, makes them self-conscious about their appearance.
• History of Trauma or Abuse: Traumatic events or abuse also increase the likelihood that someone will develop bulimia. People who have experienced these events may feel they need to control their bodies to regain some sense of control in their lives.
• Young Age: Young age is another risk factor for bulimia nervosa. Although it can occur at any age, young people between ages 12-25 have consistently recorded most cases of bulimia.
• Mental Disorders: People with bipolar disorder, depression, or anxiety are often at risk of developing eating disorders like bulimia. These mental illnesses may create an environment where binge eating and purging become a coping mechanism for some people.

Causes and Influences of Bulimia

Many factors contribute to developing bulimia nervosa, including:

• Low Self-Esteem: People with bulimia tend to have low self-esteem and may feel their bodies are not good enough. The eating habits they develop can help them cope with these feelings.
• Pressure from Family Members to Be Thin: Family members may try to influence a person’s weight in various ways. Some parents, for example, may tell their daughters they are too heavy and need to lose weight. Such comments can significantly impact a girl’s self-esteem and body image. These types of pressures from family members can contribute to the development of bulimia nervosa.
• Culture: Cultural influences such as media images promoting thinness and perfectionism among women and men can also trigger bulimia.
• Bullying: Bullying can be physical or emotional and happen in person or online. It can be overt or subtle, but no matter what form it takes, it dramatically impacts how someone feels about themselves. Bullying can lead to low self-esteem, which may trigger an eating disorder such as bulimia.

Negative Consequences of Bulimia

Bulimia can have a significant impact on your physical health if left unchecked. Understanding the short-term and long-term effects is essential to get help as soon as possible.

Short-Term Effects

The short-term effects of bulimia are primarily related to the physical health of the person with bulimia, including:

• Sore Throat: Sore throat is a common short-term effect of bulimia caused by self-induced vomiting. Frequent vomiting will irritate your throat tissue over time until it becomes inflamed enough to cause pain when swallowing food or drinking.
• Dry Skin and Hair Loss: Bulimia causes dehydration, leading to dry skin and hair loss. Dry skin may look dull and lifeless, while dry hair is likelier to break off easily or thin out over time.
• Acid Reflux and Heartburn: Many people who have bulimia experience acid reflux and heartburn. Due to frequent purging, an impaired sphincter muscle may allow digestive juices to flow back into the esophagus—which can cause painful symptoms.
• Inflamed Salivary Glands: When you vomit after eating, it causes inflammation in your salivary glands, leading to swelling in the mouth and throat—making it difficult to eat or speak properly.
• Dehydration: The vomiting and diarrhea associated with bulimia cause dehydration due to excessively losing water, leading to dizziness and fainting. If you’re experiencing these symptoms, get medical help immediately. The effects of dehydration and losing essential nutrients through purging will also result in dry skin, hair loss, and brittle nails.
• Dizziness: If you’re not eating enough food or taking enough water to replace what you’re losing through vomiting and diarrhea, your blood sugar levels will drop—and that’s when dizziness comes into play. To stabilize your blood sugar levels, you need to have a normal diet; otherwise, you’ll risk passing out.

Long-Term Effects of Bulimia

Bulimia may cause serious, long-term health problems, including:

• Tooth Decay / Enamel Erosion: Dental erosion in bulimics occurs due to self-induced vomiting. This acidic substance can decay the tooth enamel and lead to cavities. Frequent exposure to stomach acid and food particles in vomit can also cause gum disease and periodontal pockets (gum pockets), leading to tooth loss.
• Osteoporosis: Osteoporosis is a condition that causes bones to become weak and break easily. Without enough calcium due to poor nutrition, your body can’t make new bone cells as it should, leading to weak bones that are more likely to fracture.
• Heart Problems: People with bulimia often have abnormal heart rhythms called arrhythmias and high blood pressure. Arrhythmias increase the risk of heart attack and sudden death in young women with bulimia, while high blood pressure increases your risk of stroke and kidney failure.
• Gastrointestinal Problems: Because bulimia involves vomiting, it can cause acid reflux (GERD) and damage the esophagus. In addition, purging often leads to diarrhea during or after bingeing, causing dehydration and leading to severe constipation. Frequent use of laxatives can also cause ulcers in the lining of the intestines.
• Electrolyte Imbalance: The repeated vomiting associated with bulimia can cause an electrolyte imbalance and irregular heartbeat. Electrolytes are minerals, such as sodium and potassium, that help regulate your body’s water balance and electrical activity. Having too much or too little of these substances in your blood can affect the heart’s and other organs’ normal functioning.
• Kidney Failure: Repeated vomiting causes the body to lose a lot of water, important nutrients, and minerals. Without these nutrients, the kidneys cannot properly filter waste products from your blood leading to kidney failure if left untreated.

Bulimia Data Statistics

Lifetime prevalence estimates of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) state that:

• Anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women .3%, .5%, and 2% among men
• .3%, .5%, and 2% among men. When retrospectively assessed, the risk of bulimia nervosa and binge eating disorder increased with each successive birth cohort.
• All three disorders are commonly co-occurring with many other DSM-5 disorders.
• The National Eating Disorders Association estimates that 1% of young women and 0.1% of young men will have bulimia nervosa at some point in their lifetime.
• A study by Statista revealed that Bulimia Nervosa accounted for more than 9.6% of U.S. deaths due to eating disorders in 2018 and 2019.

Diagnosis and Treatment of Bulimia

Bulimia is a severe mental health condition that can cause tremendous damage to the body and mind. It is important to understand the symptoms and signs of bulimia and how it is diagnosed and treated.

How is Bulimia Diagnosed?

Diagnosing bulimia involves thoroughly assessing the patient’s medical history, physical exam, and mental health status. You will expect a doctor, psychologist, or mental healthcare professional to perform the diagnosis.

The gold standard for diagnosing bulimia is the DSM-5 criteria for bulimia nervosa, including:

• Recurrent binge eating episodes. The following two define an episode of binge eating:
  • Eating a larger amount of food within a certain period (a 2-hr period) than most people would eat in the same time and conditions.
  • A feeling of being unable to control one’s eating during an episode (e.g., a sense that one cannot stop or is not in control of what they are eating).
• Repeatedly engaging in inappropriate compensatory behavior to prevent weight gain, such as:
  • Self-induced vomiting
  • Misuse of laxatives, diuretics, or other medications
  • Fasting
  • Excessive exercise
• Binge eating and inappropriate compensatory behaviors occur weekly for three months or more.
• Body shape and weight have a strong impact on one’s self-evaluation.
• The disturbance is not limited to episodes of anorexia nervosa.

Other assessments for bulimia nervosa include:

Physical Examination for Assessments of Bulimia

This step may include evaluating the patient’s weight, height, and body fat percentage. The doctor will also check for other medical conditions related to bulimia, such as anorexia nervosa and depression.

Psychiatric Interviews

The most common way to diagnose bulimia nervosa is through an interview with a professional with experience treating eating disorders.

The doctor will ask questions about:

• The patient’s mental health status
• Eating habits and behaviors, including how often they binge eat or purge after eating
• Weight history
• Exercise habits
• Substance use patterns (both legal and illegal)
• Mood changes over time
• Sleeping patterns
• Any other symptom the patient experiences when they are not eating normally (for example, loss of appetite)

Blood Tests and Other Tests

Blood tests and additional testing help check for any related health complications from bulimia and ensure no other medical problems are causing your symptoms.

The doctor may also recommend an electrocardiogram (ECG/EKG). The ECG measures the heart’s rhythm, and electrical activity, while the EKG measures the electrical signals in the heart.

Treatment for Bulimia Nervosa

After diagnosing someone with bulimia nervosa, doctors then move on to treatment options for this disorder. Most people with bulimia nervosa require psychotherapy sessions with a therapist specializing in eating disorders and medical care.

Psychotherapy

There are many treatment options for bulimia. The most common option is psychotherapy, which can help people with bulimia understand their eating disorder and learn how to cope with it more healthily. This form of treatment includes multiple variations.

• Cognitive Behavioral Therapy (CBT): CBT is often used as an effective psychotherapy for this condition. CBT focuses on helping you change your behavior by changing how you think about yourself, your goals, and your relationship with others. In CBT, a therapist helps you identify unhealthy patterns in your life and teach you practical skills that will help you manage those patterns more effectively.
• Individual Therapy: Individual therapy helps you identify the triggers that cause you to want to binge so that you can avoid those triggers in the future.
• Family-based Therapy (FBT): Family-based therapy can also be helpful for many people with bulimia. This therapy involves you and your family members working together to develop healthier eating habits and good coping skills.
• Interpersonal Psychotherapy (IPT): Interpersonal psychotherapy (IPT) is a type of psychotherapy that focuses on improving your relationships with others. This treatment helps you learn how to deal with interpersonal problems that may contribute to your eating disorder.

Group Therapy

• Group therapy helps people with similar problems find support and encouragement from others going through the same thing. This process can be especially helpful if you feel you’re struggling alone in your battle with bulimia.

Medical Care

• Medical care is often another important part of treating bulimia. You may need treatment in an intensive care unit or a hospital setting if you have severe symptoms or complications from your eating disorder.
• The staff will be able to monitor your health closely and provide treatment for any medical problems that arise during this period.

Nutritional Counseling

• Nutritional counseling involves learning healthy eating habits to develop a healthier relationship with food and eating. It can include educating patients on the benefits of eating regular meals throughout the day instead of just one large meal at night.

Medication

• A doctor may prescribe antidepressants, anti-anxiety drugs, and mood stabilizers to help manage symptoms of bulimia. Medication is always combined with psychotherapy for a more effective result.

How Friends and Family Members Can Help Someone with Bulimia

Bulimia can be a tough thing for a loved one to deal with. It’s not something that happens overnight and doesn’t just disappear.

Bulimia is an illness; like any mental illness, getting better takes time and patience. You can support your loved one by being there for them and helping them through this difficult time.

If you’re worried about a loved one who might be struggling with bulimia, here are some important things to keep in mind:

Do

• Talk about it: You might be afraid of bringing up the topic of bulimia, but don’t worry—it’s not taboo! You’re doing your loved one a favor by being open with them about what’s going on in their lives, whether it’s good or bad news. (Just remember to be considerate of their feelings)
• Be supportive. Listen without judgment if your loved one wants to talk about their feelings. Let them know you’re there for them and that they don’t have to do this alone.
• Help them find treatment. If your loved one is ready to seek help but doesn’t know how or where to start, offer to help them look for treatment options in your area.
• Encourage healthy eating habits. Ensure your loved one is eating enough food at each meal so they don’t feel like they have to purge after overeating food—it may help keep them from engaging in unhealthy compensatory behaviors.
• Listen. Make sure to listen to them when they tell you they’re struggling with their eating habits or how they feel about food and their body.
• Ask If You Can Help. Ask if there’s anything more you can do to help them feel less alone or anxious during this difficult time.
• Be there for them. Offer company when they’re feeling down (or just bored) so they won’t resort to binge eating as a way of coping.

Don’t

• Don’t judge. Bulimia is not a choice; it is a serious mental illness.
• Don’t make comments about weight, eating, or dieting. Eating disorders are very sensitive topics for people, and it’s important to avoid saying anything that seems negative.
• Don’t force them into treatment, but let them know that you’re there for them and that you care about their well-being—even if it means keeping certain information private until they’re ready to share it with others.
• Don’t make assumptions. Avoid making comments that imply they are at fault or need help because of their choices. Instead, talk about how much you love and want them healthy—this will go a long way!
• Don’t give up on them when they relapse—it happens, but keep trying different approaches until something works!

It’s also important to understand that one cannot recover from bulimia overnight or even in a few weeks. Eating disorders are complex and require much work and support from loved ones and the person with the disorder to treat successfully.

Get Help for Bulimia Nervosa

If you or a loved one is struggling with bulimia nervosa, there’s no need to keep it a secret. Help is available for you.

Contact SAMHSA’s Treatment Facility Locator at FindTreatment.gov or call 1-800-662-HELP (4357) to find a treatment facility near you.