Bulimia Nervosa: Signs, Side Effects and Treatments

Bulimia is one of the most common and potentially life-threatening eating disorders. It is estimated that 1% of Americans will experience bulimia at some point in their life. This makes it about twice as common as anorexia and about half as common as binge eating disorder [1]. Because it is so often carried out in secret, the behaviors and symptoms of bulimia can be hard to spot. However, early detection and treatment are critical to minimizing the disorder’s most serious long-term health effects. 

Here are the most common signs and symptoms and the most effective treatments for bulimia nervosa.

What is Bulimia Nervosa?

The DSM-5 criteria for diagnosing bulimia nervosa include the following [2]: 

• Periods of binge eating and purging, occurring at least once per week for 3 months
  • According to the DSM-5, binge eating is characterized by both of the following criteria: 
    • In a short time period, eating significantly more than the average person would eat during the same time period and under similar circumstances
    • Feeling as if you cannot control the amount of food you’re eating or the types of food you’re eating
• Compensatory behaviors to prevent weight gain, such as self-induced vomiting, laxative use, compulsive exercise, or fasting; these behaviors occur at least once a week for 3 months
• Body weight, shape, and size have an extreme influence on one’s own self-evaluation
• These symptoms do not occur in the presence of anorexia nervosa

Bulimia nervosa affects both men and women but occurs 5 times more often in women. Even so, males may be less likely to be diagnosed than women, which means the actual incidences of bulimia among the male population are unknown. 

Nearly 95% of people with bulimia have co-occurring mental health conditions like anxiety, depression, mood disorders, or substance use disorders.1 Those suffering from bulimia may also struggle with impulse control, leading to issues with gambling, risky sexual behaviors, self-harming, impulsive shopping behaviors, shoplifting, or driving under the influence of alcohol [2]. 

How is bulimia different from other eating disorders?

While bulimia shares symptoms and features with many other eating disorders, it is a unique diagnosis with specific characteristics:

• People with bulimia regularly binge and purge. People with anorexia often purge, but they may not binge eat or may rarely binge eat.
• Bulimia is characterized by binge eating followed by compensatory behaviors like excessive exercise, vomiting, or laxative use. People with binge eating disorders regularly binge eat, but they do not engage in compensatory behaviors afterward.  
• Purging disorder, a type of Otherwise Specified Feeding or Eating Disorder (OSFED), does not include episodes of binge eating; however, it is characterized by compensatory behaviors to prevent weight gain [3].

It’s important to note that many people experience eating disorder symptoms on a continuum and may cycle through symptoms of multiple eating disorders over a period of years. Regardless of current or past symptoms, treatment is crucial to minimizing the long-term health effects of disordered eating.

Common Signs and Symptoms of Bulimia

While many of the behaviors of bulimia occur in secret, parents and loved ones who are educated on the warning signs are better equipped to intervene early and get their loved ones into treatment. 

Behavioral and psychological symptoms 

Behavioral signs of bulimia often occur before physical symptoms. 

Some common behavioral signs include, but are not limited to: 

• Extreme fear of gaining weight
• Fixation and concern over body shape, body weight, or appearance
• Having a distorted negative body image
• Hiding food
• Repeated episodes of eating large amounts of food in a single sitting
• Going to the bathroom during or directly following meals
• Spending a long time in the bathroom after eating
• Periods of extreme dieting and calorie restriction

Physical symptoms

Physical signs of bulimia typically appear after repeated episodes of purging. 

Specific symptoms vary depending on the type of purging involved (self-induced vomiting, laxative use, diuretics, excessive exercise, etc.) but often include the following:

• Swollen cheeks from the enlargement of salivary glands caused by self-induced vomiting
• Sore throat and pain in the esophagus from self-induced vomiting
• Gastrointestinal issues, including nausea, diarrhea, and constipation
• Weakness, faintness, dizziness
• Tooth decay and bad breath
• Dehydration
• Fatigue
• Low blood pressure

What is Russell’s Sign?

Also known as “bulimia knuckles,” Russell’s sign is noticeable scarring or calluses on the knuckles or back of a person’s hand. It is caused by the repeated scraping of the knuckles and fingers against the incisors (front teeth) during self-induced vomiting. Russell’s sign is one of the only physical signs of bulimia and may also be present in individuals with anorexia. 

It’s important to note that not everyone who has bulimia will display Russell’s sign; only those who purge by using their fingers to induce vomiting will have the characteristic knuckle scarring. 

People who purge using laxatives, diuretics, or excessive exercise will not have Russell’s sign, but they may show other, more subtle signs of bulimia. 

Potential long-term effects and complications of bulimia

Bulimia can cause severe, sometimes irreversible damage to multiple organ systems:

• Repeated self-induced vomiting exposes the throat and mouth to highly acidic stomach acid, which, over time, can cause tooth decay, gum sensitivity, and even tooth loss. It may also cause ulcers and lesions in the esophagus and may even lead to an esophageal rupture. 
• Frequent vomiting is associated with swelling and damage to the throat and vocal cords; this leads to hoarseness, chronic discomfort, persistent cough, and difficulty swallowing.
• Individuals who purge using laxatives have an increased risk of lazy colon, irritable bowel syndrome, and colon cancer. 
• People with bulimia are at higher risk for cardiac complications than people without bulimia. Repeated purging through self-induced vomiting or laxative use causes severe fluctuations in fluid and electrolyte levels; this can result in an increased heart rate and low blood pressure. 
• Low potassium levels—another common side effect of purging in bulimia— can cause an abnormal heart rhythm called a prolonged QT interval. This is usually detected during an EKG (electrocardiogram) and, if untreated, can be fatal. [4]. 
• Bulimia can increase the risk of heart disease. Studies have shown that women with a history of bulimia are at increased risk of atherosclerosis (hardening of arteries) and ischemic heart disease (narrowing of arteries) [5].

Treatment for Bulimia

The most effective treatment for bulimia nervosa involves a multi-disciplinary team of eating disorder specialists.

Individual therapy is an essential step toward recovery. Your therapist may use a combination of therapeutic modalities to help you identify unhelpful thought patterns and shift your behaviors over time. Therapy can also equip you with coping mechanisms to manage anxiety and triggers associated with your eating disorder. 

Medical nutrition therapy is another core aspect of bulimia treatment. Your registered dietitian will identify your unique strengths and challenges surrounding food. They will also work alongside you to heal your relationship with food as you learn to nourish your body.

Because bulimia can cause severe, life-threatening medical issues, it is important to work with a medical doctor or advanced practice provider to monitor for health complications like cardiac abnormalities, gastrointestinal issues, and electrolyte imbalances. 

Your doctor may also prescribe medications to help you manage your symptoms. The only medication specifically approved to treat bulimia nervosa is fluoxetine (Prozac).6 Other medications may be effective in treating co-occurring mental health conditions, like anxiety, depression, OCD, or bipolar disorder. When these other conditions are managed, the underlying causes of an eating disorder often improve as well. 

At Selah House, we believe in personalized, whole-person eating disorder treatment plans that meet our clients where they are. We offer treatment options that go beyond traditional talk therapy, including art programs, yoga, equine therapy, and family programming. We are committed to helping everyone in our treatment programs find the path to recovery and healing that works for them. 

To learn more, complete our contact form or give us a call at 866-324-8081.

 

References

1.  https://www.nimh.nih.gov/health/statistics/eating-disorders
2. https://www.nationaleatingdisorders.org/bulimia-nervosa/ 
3. https://www.nationaleatingdisorders.org/osfed/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392812/
5. https://pubmed.ncbi.nlm.nih.gov/31617882/#:~:text=Bulimia%20nervosa%20was%20found%20to,CI%2C%201.57%2D5.71
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10243293/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10243293/