What is Bulimia: Symptoms, Complications and Causes

Bulimia Nervosa is a troubling mental illness and eating disorder that can have severe lifetime consequences. For those that struggle with this disorder, overcoming the complicated behaviors of the disorder as well as the misperceptions and stigmas associated with it can be incredibly difficult.

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    Approximately 1% of individuals with bulimia nervosa will struggle for their lifetime. Increasing awareness of symptoms, causes, and interventions of bulimia nervosa can result in a meaningful reduction of this prevalence.

    Bulimia Meaning

    The term “bulimia nervosa” refers to an eating disorder characterized by episodes of binge eating that are followed by compensatory behaviors such as purging, fasting, and/or excessive exercise.

    bulimia defined

    Bulimia Definition According to the DSM-5

    The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines the diagnostic criteria that must be met for an individual to be diagnosed with a specific mental illness.

    For bulimia nervosa, the DSM-5 specifies the following criteria:

    1. Recurrent episodes of binge eating, which are characterized by BOTH of the following
    • “Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
    1. Recurrent, inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
    2. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
    3. Self-evaluation is unduly influenced by body shape and weight.
    4. The disturbance does not occur exclusively during episodes of anorexia nervosa [1].

    ICD-10 Code for Bulimia Nervosa

    Each culture varies in its medical and mental health diagnostic terminology. For this reason, the International Classification of Disease (ICD-10) designates specific codes that allow diagnoses to be communicated regardless of cultural differences.

    The ICD-10 code for Bulimia Nervosa is F50.2

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    Bulimia Statistics

    While many are aware of bulimia, the impact it has on various populations, as well as its prevalence, is less known.

    • .3% of the US population will struggle with bulimia in their lifetime [2].
    • 4% of females in the US will experience bulimia nervosa, which is 5X that of males [3] [2].
    • 78% of those with bulimia nervosa experience daily life impairment and 43.9% experience severe impairment [2].
    • Only 43% of those with bulimia nervosa receive treatment [2].
    • 3.9% of those with bulimia nervosa will die from their disorder [4].

    Types of Bulimia Nervosa

    Due to the complexity of Bulimia Nervosa symptoms and behaviors, they are often divided into two subtypes: Purging Type and Non-Purging Type.

    Bulimia Nervosa – Purging Type refers to the most commonly understood version of Bulimia Nervosa behaviors. Purging Type involves the individual engaging in the above-mentioned binge eating behaviors followed by purging behaviors such as vomiting and/or laxative/diuretics/enemas.

    Bulimia Nervosa – Non-Purging Type does not mean that individuals do not engage in compensatory behaviors intended to “undo” binge-eating behaviors. Those that struggle with non-purging bulimia engage in compensatory behaviors that do not actively involve expelling the food from the body. Instead, these individuals will engage in fasting or exercising behaviors to compensate and do not regularly engage in purging behaviors if they do at all.

    Bulimia Nervosa Symptoms

    The best way to combat bulimia and increase the likelihood of long-term recovery is early intervention. This begins with early detection through awareness of symptoms and signs of bulimia.

    Physical Signs

    Bulimia Nervosa is an intensely physical disorder, resulting in apparent changes to the body that can warn an individual is struggling, such as:

    • Weight fluctuations.
    • Chronically inflamed or sore throat.
    • Swollen salivary glands around the neck and jaw.
    • Worn tooth enamel/yellowing teeth and tooth sensitivity due to exposure to stomach acid.
    • “Acid reflux disorder and other gastrointestinal problems [5].”
    • “Intestinal distress and irritation from laxative abuse [5].”
    • Severe dehydration due to fluid loss from purging.
    • Electrolyte Imbalance.
    • Scars on knuckles or hands from self-induced vomiting (also known as “Russell’s Sign”).
    • Puffy cheeks.
    • Appearing bloated from fluid retention.
    • Bright red eyes, bursting of blood vessels in eyes due to vomiting or straining in vomiting.
    • Smelling of vomit.

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    Behavioral Warning Signs

    Behavioral red flags of bulimia are not as easily identifiable as the physical listed above; however, it is still possible to recognize behavioral changes that could indicate a problem, for example:

    • Engaging in binge eating episodes.
    • Distress over body shape/weight/size and/or negative body image.
    • Expressing shame or guilt around eating.
    • Frequently going to the bathroom during or immediately after meals.
    • Increased irritability.
    • Increased depression and suicidal ideation or self-harming behaviors.
    • Withdrawal from family and friends, particularly in situations related to food or during/after meals.
    • Uncomfortable eating food around others.
    • Buying/hoarding diuretics/laxatives.
    • Hiding food.
    • Drinking excessive amounts of water.
    bathroom sign

    What are the Long-Term Effects of Bulimia?

    The body is created to consume food, absorb the necessary nutrients, and then get rid of what is not needed for optimal body functioning.

    It is not surprising then that bulimic behaviors result in serious long-term consequences to the physical functioning of the body, which include:

    • Digestive Issues.
    • Irregular Heartbeat/Cardiovascular issues/heart attack or failure.
    • Cardiomyopathy.
    • Coronary heart disease.
    • Gum disease and tooth decay/tooth loss.
    • Mental health disorders such as anxiety, depression, substance use issues, etc.
    • Dehydration and organ issues/failure.
    • Increased suicidal ideation.
    • Irregular menstrual cycles and fertility issues.
    • Low bone density.
    • Osteopenia.
    • Osteoporosis.
    • Ulcers in the lining of the intestine.
    • Irritable Bowel Syndrome (IBS).
    • Bowel perforation.
    • Possible colon resection.
    • Use of a colostomy bag.
    • Damage to esophageal sphincter and esophagus.
    • Chronic Acid Reflux disease.
    • Esophageal cancer.
    • Death due to the physical impacts mentioned above or increased suicidal ideation.
    The Effects of Bulimia on the Body

    What are the Causes of Bulimia?

    As with most mental illnesses and eating disorders, there is no one cause of bulimia nervosa. Numerous factors related to one’s genetic make-up, environmental and social upbringing, and psychological history can lead to bulimia nervosa behaviors.

    Biological Factors

    Biological Factors

    There are a few genetic and biological factors that are associated with the development of bulimia nervosa, such as:

    • Family history of eating disorders/bulimia nervosa.
    • Family history of mental illness/substance use.
    • Predisposition to impulsivity/impulse control difficulties.
    • Predisposition to binge eating.
    • Neural sensitivity to rewards, particularly food reward systems.
    Psychological Factors

    Psychological Factors

    Bulimia nervosa is associated with specific behavioral pathology, including:

    • Prior mental health diagnosis.
    • Tendency for impulsivity.
    • History of abuse or trauma.
    • Negative body image or self image.
    • Impaired emotion regulation and distress tolerance capabilities.
    • Poor self-esteem.
    • Engaging in a career or hobby focused on physical appearance.
    Dieting Factors

    Dieting Factors

    Development of bulimia nervosa is closely associated with a history of dieting and engagement in diet culture behaviors, some of which include:

    • Dissatisfaction with body weight/shape/size.
    • Negative self-view related to appearance.
    • Any history of dieting behaviors.
    • Any history of engaging in restricting and bingeing cycles.
    • Overvaluation of eurocentric beauty ideals.
    • Core beliefs equating fulfillment with appearance.

    Bulimia Nervosa Treatment Options

    There are various therapeutic modalities recommended to treat bulimia nervosa that are proven to be effective. One of these is Cognitive Behavioral Therapy (CBT), which focuses on the limiting and unhelpful beliefs one might have that fuel bulimic behaviors and supports the individual in replacing these with beliefs that support recovery. Family-based therapy is also particularly helpful in treating eating disorders in adolescents and young adults. Additionally, many individuals with bulimia nervosa struggle with co-occurring disorders that might perpetuate bulimia behaviors, therefore, seeking out information regarding psychiatric medication may provide mood stabilization that results in behavior reduction.

    It is true that the behaviors and potential consequences of bulimia nervosa are frightening, however, do not forget that this disorder is treatable. It is possible to receive meaningful and life-changing support that allows you or your loved one to become free of this disorder and live a fulfilled and joyful life of recovery.

    1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
    2. Unknown (2017). Eating disorders. National Institute of Mental Health, Retrieved from https://www.nimh.nih.gov/health/statistics/eating-disorders.
    3. Unknown (2018). Eating disorders: facts about eating disorders and the search for solutions. The National Institute of Mental Health. Retrieved from www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml
    4. Crow, S.J., et al. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry; 166, 1342-1346.
    5. Unknown (2016). Eating disorders. The National Institute of Mental Health, Retrieved from https://www.nimh.nih.gov/health/topics/eating-disorders/.
    Margot Rittenhouse, MS, PLPC, NCC Avatar

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    Page Last Reviewed By: Jacquelyn Ekern, MS, LPC on June 30, 2020