Symptoms and Warning Signs of Bulimia Nervosa

Physical, behavioral and emotional symptoms

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People who are experiencing bulimia nervosa may exhibit some of the following symptoms and/or warning signs of the disease. Sometimes family members and friends will remark after a diagnosis has been made that they are surprised that they didn’t notice the eating disorder or didn’t realize that certain behaviors or physical complaints were related to an eating disorder. However, people who are struggling with bulimia nervosa often experience emotions of shame and guilt about their behaviors.

This means that many people with bulimia nervosa will go to great lengths to hide their behaviors to avoid anyone finding out about the eating disorder.

It is important to note that this is not an exhaustive list of symptoms and people who do not have all of the symptoms below may still be struggling with bulimia nervosa or another eating disorder. Also, these signs and symptoms are not specific to eating disorders and may reflect other conditions.

Physical Symptoms

Bulimia nervosa is characterized by

  • repeated episodes of binge eating, which is eating a large amount of food in a short period of time and feeling out of control while doing so. and
  • the use of compensatory behaviors such as vomiting, using laxatives or diuretics, or engaging in extreme amounts of exercise in order to offset eating.

Because many sufferers are of average weight, physical symptoms may not be noticeable to others until the disorder has become extremely severe.

It is important for anyone experiencing physical symptoms to be assessed by a physician.

  • mouth ulcers
  • chest pains
  • heart palpitations
  • headache
  • stomach aches
  • frequent sore throat
  • electrolyte imbalances and dehydration
  • swelling of hands and feet
  • chronic bouts of constipation (resulting from laxative abuse)
  • vomiting blood

Dentists are often the first to notice signs of self-induced vomiting in patients with bulimia nervosa because of the tell-tale pattern of dental erosion primarily on the internal surface of the teeth. Puffy cheeks among patients who vomit are one of the other noticeable physical signs. Calluses on the hand from inserting it in the mouth to cause vomiting may also be visible and are known as Russell's sign. Later in the illness this sign may not even be visible because patients are able to vomit without mechanical stimulation. 

Behavioral Symptoms

These are symptoms that are often noticed outwardly by family members and friends.

  • evidence of purging – always needing to go to the restroom or showering after meals, or finding packages of laxatives or diuretics
  • evidence of binge eating – stashing food, stealing food, eating large amounts in one sitting
  • family members or roommates may notice large amounts of food that are missing from the cabinets or pantry or notice large amounts of food packaging in trashcans or vehicles
  • frequent trips to the bathroom
  • extreme eating habits (strict dieting followed by overeating)
  • desperate to exercise even when it gets in the way of other activities
  • wanting to exercise a specific amount to ‘burn off’ the calories that have been taken in
  • creation of schedules or rituals that allow for binging and purging
  • uses drugs as a way to suppress appetite
  • talks about dieting, calories, food or weight so much that it gets in the way of regular conversation
  • withdrawal from friends, families and usual activities
  • seems fatigued

Emotional Symptoms

Although more difficult to notice than behavioral symptoms, emotional symptoms are often recognized by family members and friends, even when they don’t know about the binging and purging behaviors.

These emotional issues are not unique to bulimia nervosa, but may raise concerns.

  • self-esteem, self-worth, or attractiveness determined by appearance and weight
  • depression
  • mood swings
  • extreme irritability
  • strong need for approval
  • extremely self-critical
  • feeling out of control

Other diagnoses

Sometimes, people with anorexia nervosa will also use binging or purging behaviors. However, the distinction between bulimia nervosa and anorexia nervosa is that people struggling with anorexia nervosa have significantly low body weight. Patients who binge but do not purge, may meet criteria for binge eating disorder. 

If you or someone you know is showing signs of bulimia nervosa, please seek professional help. Most of the symptoms and signs listed above are reversible with treatment. 

Sources:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Costin, C. (2007). The eating disorder sourcebook. New York: McGraw Hill.

Mehler, Philip S. and Arnold Andersen, 2010.  Eating Disorders: A Guide to Medical Care and Complications. Baltimore: The John Hopkins University Press. 

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