Bulimia nervosa is one of the three most common types of eating disorders, along with binge eating disorder and anorexia nervosa. It typically presents with a binge period where food is eaten to excess — often in secret — and then a compensatory activity is engaged in, with the most common being a purge. The purging can be done through vomiting or laxatives in most cases, resulting in the food having less time to digest and thus, fewer calories absorbed.
Other forms of bulimia do not present in this binge-purge cycle, and we will be examining them, but regardless of the type of bulimia, the threat to the individual’s health is very real. While all eating disorders can cause damage to both psychological and physical well-being, bulimia — particularly purgative bulimia — adds a new set of complications. Identifying the physical and emotional signs of bulimia can help you get support for your loved one and ensure lifelong recovery.
We will examine the causal factors of bulimia nervosa in its various types, how you can identify it and some of the best courses of treatment that create the greatest chance of lifetime recovery. Eating disorders can be frightening but equipping yourself with knowledge is the first step towards finding a long term solution.
Primary Bulimia Nervosa
Roughly 1-2% of adult Americans will suffer from bulimia nervosa of some type in their lifetime, and while the occurrence is less than binge eating disorder or anorexia, the life-threatening implications of bulimia are extremely dangerous. Bulimia itself is typified by chronic episodes of binge eating, where a vast quantity of food is eaten in a short time, usually in secret. With the most common form of bulimia, these binge periods are usually followed by a purging period and there are typically extreme feelings of guilt, self-ridicule, and feelings of loss of control. It’s extremely common for anxiety and/or depression to affect a bulimia individual concurrently.
Behavioral signs that your loved one might be suffering from bulimia nervosa in any type, but particularly primary bulimia nervosa, are (but are not limited to):
- Emergent preoccupation with body image
- Hiding food wrappers and disappearing after a meal, particularly to the bathroom
- Avoiding social eating, even with family
- Ritualistic behavior with food, such as eating only at certain times, only allowing meals for certain durations, chewing specific amounts, etc.
- Sudden regimented behaviors that revolve around food. This is often to make room for binging and purging
- Changes in social groups, or social activities, particularly withdrawal from hobbies and extracurricular activities (in adolescents)
Physical signs and symptoms of bulimia nervosa are:
- Swelling of the jaw and cheeks
- Eroding and/or discoloration of teeth from repeated vomiting
- Callouses or erosion of the skin on the fingers of one hand from inducing vomiting
- Frequent sickness and reduced wound healing
- Swelling of the tongue
- Sweats and complaints of coldness
- Brittle nails and hair
- Sleep disturbance
Eating disorders like bulimia are often used as a method of feeling in control when life feels out of unmanageable. This is often why it strikes teenagers — the changes to body chemistry and social structures can be chaotic and confusing for children. Coupled with anxiety, OCD, PTSD or depression and the situation is very fertile for the development of an eating disorder. Individuals who have a history of PTSD or anxiety stemming from trauma are significantly more likely to develop an eating disorder than those without.
Confounding Concurrent Variables
Many individuals — particularly adolescents — who suffer from an eating disorder also have concurrent conditions that can make both identification and treatment of the primary eating disorder more difficult.
- Anxiety is prevalent in the general population and extremely co-morbid with eating disorders. Roughly 90% or more of individuals being treated for bulimia nervosa have an underlying mental health disorder like anxiety or depression that needs to be addressed concurrently in therapy. Often it can be difficult to determine the causal factor in the relationship; that is, whether the anxiety caused the ED or vice-versa, but both must be treated for either to be resolved.
- Substance abuse is common in bulimia and binge eating disorder, but less so in anorexia. Particularly with some forms of bulimia, substances like laxatives, stimulants, and diuretics are commonly misused, but bulimia individuals may also misuse drugs and alcohol to escape the pain of the condition.
- Self-harm is another manifestation of a need for control. While it can occur both concurrent and independent of other mental health disorders, it can be an external sign that you need to intervene.
External stress from peer groups or social obligations can play a confounding or even causal role in the development of eating disorders as well. An individual who is actively involved in a sport may feel pressure to maintain a certain body type and that can lead to pathologizing their self-image.
Less Common Forms Of Bulimia
While the binge-purge form of bulimia is the most common and widely-known, several other types have different indications, both for treatment and identification. Some people might not see the danger in these types of bulimia and depending on the situation, the behavior involved wouldn’t be considered pathological. In an individual for whom these behaviors are compulsive, concurrent with negative self-image or self-talk, and interfere with health and regular daily activities, they are considered pathological and disordered.
Bulimia in this form looks on the surface like a preoccupation with physical measurements and may start as a desire to reach a certain bodyweight for any number of reasons. Individuals who suffer from this type of bulimia will still binge eat and experience a loss of control, and then spend hours or days in a starvation period. They may even avoid drinking fluid to “make up” for the excessive intake of food, and not drinking can be acutely dangerous.
Again this type of bulimia can be difficult to distinguish from regular “dieting” behavior, and may only be outwardly noticeable over long periods when the effects of prolonged starvation become evident. With purging bulimia, the negative effects are almost immediately evident, but with starvation, the psychological effects can be more acutely detrimental, as they are related more to guilt or punishment. This type of bulimia can be especially difficult on the mental health of the individual because as the body eats less food, the metabolism slows down, making body change harder. In turn, this makes the individual restrict eating that much more, leading to worse binges and longer starvation periods.
Unlike purging bulimia, someone who starves themselves after a binge may not show any of the physical symptoms listed above, but there will be external physical indications. For example:
- Cognitive difficulties
- Memory impairment
- Extreme fatigue
These are due to caloric restriction — particularly glucose impairment — but also if the individual isn’t taking in food, they will likely not be getting enough electrolytes. This can cause fainting episodes but can also be severely dangerous for the heart, causing arrhythmias.
Exercise bulimia is typified by patterns of binging but also extreme amounts of exercise to off-set the caloric intake. Unlike purging or starvation, this type of bulimia doesn’t restrict food in the traditional sense. Rather, the individual will excessively and compulsively exercise. While the physical symptoms of bulimia will likely not be present here as there is no restriction or purging, the compulsion and obsession are still very present.
This particular type of bulimia can be extremely difficult to identify, particularly in people who already like to exercise quite a bit. It’s also difficult to differentiate exercise bulimia with orthorexia, another disorder entirely. Orthorexia is identified as a pathological obsession with eating a healthy diet and often includes excessive exercise. The primary difference is that someone with exercise bulimia will likely not change their eating habits, and in fact, will still exhibit binging behavior.
Identifying exercise bulimia can be extremely difficult and the signs are far more likely to be psychological than physical. In purging bulimia or even restrictive bulimia, there is a lack of nutrition and injurious behavior that causes physical weakness, sickness or general malaise. A person with exercise bulimia may appear to be outwardly healthy, particularly because they will have the energy to compulsively work out.
The primary traits to look for if you suspect your loved one is suffering from exercise bulimia are:
- Extreme preoccupation with fitness and ritualized behavior around fitness (going running despite the weather being very inclement).
- Exercising far more often than what would be considered normal for them — twice a day, seven days a week is for most people excessive.
- Exhibiting distress and anxiety when they aren’t able to exercise.
Fluctuations in weight can be a physical symptom of this disorder but that’s likely to be the only external indication. Another is continuing to exercise even if there is an injury present that would otherwise cause someone to rest and recover.
Treatment Of Bulimia In All Its Forms
No matter what form bulimia presents itself in, the key to recovery is a comprehensive treatment program that includes a registered dietitian, general practitioner, counselor, and group therapy. Studies have shown that group-therapy and out-individual treatment is far more effective at long term recovery than hospitalization. A comprehensive treatment facility like Oliver-Pyatt Centers have a significantly higher success rate than in-hospital treatment and focus on a holistic approach to healing.
Treatment at Oliver-Pyatt Centers is focused on clinical, psychiatric and medical programs designed to give the individual a sense of empowerment. As we discussed, the fact is that most eating disorders are concurrent with other eating and mental health disorders. The goal of a treatment center like these is to make the transition from the program to real life as painless as possible, while still preparing the individual for life after recovery. Hospitalization cannot mimic real-world conditions and upon completion, individuals often relapse. Holistic treatment facilities provide comprehensive care through cognitive-behavioral therapy to restructure the individual’s views on nutrition and exercise, as well as the events that lead up to the development of the eating disorder.
With medical and psychiatric resources available as well, confounding variables like substance abuse or OCD can be examined and resolved so that the root problem — the eating disorder — can be fully healed. Nutrition and exposure therapy with guided practice ensures that nothing happens too quickly to minimize adverse reactions or regression.
Aftercare And Beyond
You shouldn’t try to resolve eating disorders on your own, and you needn’t have to. A comprehensive plan to full-body and mind health is substantially more likely to result in lifelong recovery than trying to go it alone. Hospitalization often results in negative reactions, including rejection of treatment protocols and regression of the eating disorder.
Identifying the disorders troubling your loved one and the need for intervention is the first step in ensuring that they can heal and live a full life. Getting help is critical for long term recovery and the programs at Oliver-Pyatt facilities are specifically designed to treat eating disorders. You and your loved one deserve the highest quality care and part of that is leaving treatment with a concrete aftercare program in place. This includes visits with a counselor, nutritionist, and your medical doctor to ensure compliance and healthy habits stay in place after long into recovery. Identification, treatment, recovery, and aftercare; these are all steps on the road to living a full, happy life after an eating disorder.