Bulimia Nervosa, or binge/purge disorder, can be difficult to identify because those affected are often of normal weight (or even “overweight”) and don’t raise red flags with friends and family because they continue to eat normally around others and hide their bulimia symptoms. Those with bulimia usually feel shame about their disorder and the symptoms of bulimia and go to great lengths to hide their disorder. By the time healthcare providers begin to see the effects of the bulimia symptoms, the disorder is often entrenched and harder to treat, so it’s best not to ignore the warning signs.
What is Bulimia?
Bulimia is characterized by episodes of binge eating (with a frequency of at least once per week for three months). The amount of food consumed is larger than what most people would eat in the same circumstances and same time frame and is characterized by a lack of control over the food consumption.
Individuals with bulimia engage in compensatory behaviors to in an attempt “undo the damage” of the binge. Common behaviors include: self-induced vomiting, laxative, diuretic and/or other medication abuse, periods of fasting, and excessive exercise.
The self-evaluation of those with bulimia is unduly influenced by body shape and weight. The binge/purge cycle is one where the binge and purge episodes may each initially be experienced as calming, but are then generally followed by feelings of shame and self-loathing. Some individuals describe bingeing and purging as addictive; this is likely because these behaviors have been reinforced over time by the reduction in anxiety that occurs following them.
What Causes Bulimia?
It’s important to understand that bulimia and other eating disorders are serious mental illnesses with physical complications and the affected individuals do not choose to have bulimia.
Eating disorders are genetic, biologically-based, and environmentally-influenced; for an up-to-date understanding and an idea of what new research avenues are revealing, please watch this video by Dr. Laura Hill, titled Eating Disorders from the Inside Out:
Isolating the cause of an eating disorder is not possible with our current knowledge base and is less important than getting necessary treatment.
Signs and Symptoms of Bulimia
Since someone with bulimia normally works hard to keep his/her illness a secret, these are some signs to look for if you suspect a loved one or friend may be struggling with this mental illness. These are common bulimia symptoms and some of the behaviors that you can be alert for.
Bulimia Symptoms to Look For
- Vomiting after meals
- Disappearing to the bathroom or showering directly after eating
- Rigid dieting/food restriction in the presence of others
- Obsession with weight/body size
- Large amounts of food disappearing
- Hidden food/candy wrappers
- Laxative wrappers (laxative use is a form of purging)
- Extreme exercise (this is purging through exercise)
- Hidden bags of vomit
- Bloating and constipation
- Frequent heartburn and indigestion
- Irregular menstrual periods in females
- Vomiting blood
- Dental issues
- Bloodshot eyes
- “Chipmunk” cheeks (swollen neck and/or facial glands)
- Calluses on the knuckles or backs of hands (this is known as Russell’s sign)
What to do if you suspect a friend or loved one has bulimia?
The most important thing to do is educate yourself as you are doing by reading this. Look for current information as there is considerable outdated material still in circulation. Reputable sites include (but are not limited to) F.E.A.S.T. (International), NEDA (U.S.), NIED (Canada), B.E.A.T. (U.K.) and Butterfly Foundation (Australia).
How you approach your friend and loved one will vary depending on the level of influence you have and your role in the person’s life. The affected individual will likely deny he/she has a problem; he/she may try to manipulate you or convince you there is no problem. The secrecy and manipulation are symptoms of the disorder, so it’s best to remain calm and not shame the person further. Threats do not help. Speak and listen with empathy and keep the focus on how to get the person help. Make note of the evidence you have gathered that has brought you to the point of having this discussion.
If this person is your friend and under 18, please tell a reliable adult such as his/her parent, partner, school nurse, etc. about your suspicions. Untreated bulimia can and does result in death. If you are the parent or partner of someone with bulimia who refuses to acknowledge their illness or admit it’s a problem, please follow up with a reputable eating disorder clinician yourself for guidance on how to proceed. As with addiction disorders, sometimes an intervention is needed. Peer support can be very helpful and there are a variety of support groups on Facebook. The FEAST forum Around The Dinner Table is an excellent place to reach out to others for education and connecting with those with lived experience.
Is There Hope?
There is always hope! As with any illness, early detection and intervention makes an eating disorder easier to treat, but it is never too late to begin recovering from an eating disorder. Cognitive Behavioral Therapy (CBT) is the current treatment of choice for bulimia nervosa and many people have been helped. CBT should be in combination with full, ongoing nutrition and should address any other issues such as trauma. Depending upon the duration and severity of the illness, treatment options range from the outpatient setting to intensive outpatient or partial hospitalization programs to residential treatment or inpatient hospitalization. Recovering and staying in recovery from bulimia is not a quick process and family and friends can be vital in supporting long-term recovery.
You can follow these links for more information on eating disorder denial (anosognosia) and the effects of bulimia. Some additional bulemia articles of interest include statistics on bulimia and how bulimia affects the teeth.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC
Rushing, J. M., Jones, L. E., & Carney, C. P. (2003). Bulimia Nervosa: A Primary Care Review. Primary Care Companion to The Journal of Clinical Psychiatry, 5(5), 217–224.
About The Author:
JD Ouellette is an educator and the mother of a young adult in strong recovery from anorexia. She is a member of the UCSD Eating Disorders Center’s Parent Advisory Committee, a parent mentor for UCSD, an active member of Eating Disorder Parent Support, a co-ed online support community, and co-administrates International Eating Disorder Action and a member of the Joint Commission’s Behavioral Health Care Professional and Technical Advisory Committee.
Written – 2015