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.

What is the Meaning of Bulimia Nervosa?

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 According to the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) specifies 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

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.

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.

Non-Purging Type

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.

Related Reading

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 signs and symptoms.

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.

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

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

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

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.

Resources

  • [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/.

Articles on Bulimia Nervosa

  • Recovery from an eating disorder is difficult and there are many opportunities to backslide into old habits. There are tools available that will help in the continued journey of recovery after the completion of treatment. Dr. Jantz has composed five essentials that will aid in the continued success of recovering.
  • One of the more detrimental and common side effects involves dental damage. The negative ways in which teeth are impacted is often overshadowed by other major health consequences, such as cardiovascular complications, electrolyte imbalances, gastrointestinal distress, and bone loss.
  • Trying to getting insurance coverage for bulimia is a confusing and frustrating experience for many patients, families and treatment providers. Several factors play into the difficulties.
  • Interpersonal Therapy is based on a simple idea: how you relate to others impacts your emotional and mental health. This idea grew out of the work of a psychiatrist named Harry Stack Sullivan who believed that an individual’s personality was significantly influenced by his/her interpersonal relationships.
  • Bulimia Nervosa is an eating disorder that is characterized by “a cycle of bingeing, self-induced vomiting and other compensatory behaviors such as starving designed to undo or compensate for the effects of binge eating.”
  • Do you believe your child has an eating disorder? Let’s define what bulimia nervosa is, and why it can be difficult to detect –– even among a family member.
  • Weight fluctuations can be a common occurrence within a healthy individual. One’s body weight can fluctuate on average 2 to 4 pounds per day. However, individuals who consistently engage in chronic dieting behavior, as well as individuals suffering from bulimia nervosa, experience weight fluctuations beyond the normal day to day variance.
  • Bulimia Nervosa is a psychological disorder resulting in devastating health consequences if left untreated.  New research findings are creating more effective methods and approaches for treatment, which can improve outcomes for individuals seeking recovery from this eating disorder.  Addressing the underlying issues related to bulimia along with the use of effective psychotherapy methods can dramatically improve the chances for recovery.  Learn more about these new research findings for bulimia treatment in this article.
  • Often times, men and women with eating disorders may not appear as though they are struggling.  Part of this is due to the fact that eating disordered behaviors are hidden and may not be as obvious to concerned family and friends.  This is especially true where binge and purge cycles are usually done in secret.  This secrecy can allow individuals suffering from Bulimia to do so for several years before seeking help.  If you are concerned that someone you care about may be struggling with this issue, read this article to learn more about identifying signs and tips for approaching your loved one.
  • Add the chaos and pressure from the transition to college life and the lifestyle changes this involves, and the perfect storm may be created for college students struggling with this eating disorder.
  • Is it possible to be compelled to lose weight for reasons other than aesthetics? Last but not least to ask is, whether there are external forces that reinforce weight loss in order to achieve success in an occupation or avocation?
  • I would like to examine some of those differences to illustrate how an obvious, general similarity can obscure a telling difference. Exercise, body image, and the effects of media among males are prime examples where apparent similarities with females can obscure crucial differences.
  • One behavior that differentiates non-athletes with bulimia from athletes with bulimia is the athlete’s use of exercise as the predominant purging method. Because excessive exercise is a normative behavior in competitive athletes, exercising as a compensatory behavior may go unrecognized, thus putting the athlete at physical and psychological risk.
  • While it has devastating effects on an individual’s mental and physical health, it also affects the entire family. When a loved one is struggling tension is often created within the family unit.
  • Eating disorders are often said to be both compulsive and impulsive. Compulsive means to act repeatedly on an irresistible urge. Impulsive means to act without thought, to act on a whim. So, eating disorders are repeated behavior, often taken without thought. Now, I’m no doctor, but that sounds right to me. What about the link between specific manifestations of an eating disorder and impulsivity, though? How does bulimia intersect with impulsive behavior? Let’s find out.
  • When a bulimic individual purges their body, they are inadvertently robbing their body of insulin. This is the same with a diabetic who purges or limits their insulin injections. For this reason, diabetics have a higher chance of becoming bulimic, compared to individuals who are not. Young women with Type One diabetes are shown to be 2.4 times more likely to develop some form of eating disorder.
  • The National Center on Addiction and Substance Abuse has shown that approximately 35 percent of all women who suffer from alcoholism also suffer from an eating disorder. Eating disorder sufferers also have an increased risk of abusing alcohol or illicit drugs, with studies revealing that up to 50 percent of individuals with eating disorders simultaneously struggling with substance abuse.
  • For a mother who is trying to raise a family while also dealing with an eating disorder, the struggles encountered are much more intense and forceful. The effects of a severe psychiatric illness are wearisome for any individual who may be suffering from this disorder.
  • Unless we have lived it ourselves, it may seem clouded in mystery. Without the facts, misinformation circulates. If we want to be part of the solution, we do well to become more informed about this troubling psychological disorder. Here are a few common misunderstandings.
  • Weight suppression (WS) is defined as highest ever historical weight minus current weight. It represents a measure of the level of weight lost since being at the highest ever weight achieved over a lifetime. Although the psychological and behavioral symptoms are undoubtedly the major focus in this eating disorder, it has been argued that the magnitude of weight suppression may play an important role.
  • Researchers have discovered a link between women who suffer from post-traumatic stress disorder (PTSD) and bulimia, finding that the chances of developing eating disorders are increased significantly when an individual is diagnosed with PTSD.
  • Some family members, teachers, coaches, and trusted friends may mistake this eating disorder for a “fad” that teenagers will “grow out of”, but the reality is that it can result in detrimental physical and emotional consequences, including death.
  • While headway has been made to moderate the impact of the thin-ideal in the sports and dance industries, similar pressure is yet to be applied to the beauty and fashion industries. There is little doubt that the pressure to be thin has seen an increase in eating disorders in recent years and there is much evidence that social norms and ideals can be changed. In a similar way that the public health discourse of smoking has changed radically in the last 100 years, so too, can discourse around thinness transform to occupy a new and better-informed space in the health debate.
  • As you come alongside your loved one (whether it’s your child, your spouse, or a close family member) on their road to recovery, you will find things that are in your power and things that are not. You can’t wave a magic wand and “fix” the eating disorder, but you can certainly play a vital role in the recovery process by helping to create the best possible atmosphere for healing. Here are some helpful things you can do.
  • While no single factor can be pinpointed as the cause of bulimia nervosa, the role of genetics in eating disorder development has been increasingly understood. Because the heritability factor is not as readily discussed, it seems more straightforward to base our insight on these disorders on what we know, namely what is seen in our environment.
  • For those who have struggled with Bulimia, it is easy to identify and recognized the heightened anxiety that often comes hand-in-hand with this mental illness. Whether severe anxiety is a co-occurring condition with Bulimia, if anxiety is induced by the eating disorder, or if it is used to help cope with anxiety, these two conditions are often intertwined.

Page Last Reviewed By: Jacquelyn Ekern, MS, LPC on June 30, 2020
Author: Margot Rittenhouse, MS, LPC, NCC