Bulimia nervosa: What are the warning signs?

Bulimia nervosa is an eating disorder marked by a cycle of binge eating and excessive compensatory behaviours, such as vomiting, dieting, laxative use, or excessive exercising. Research shows that, due to the shame and secrecy surrounding these bingeing and compensatory behaviours, it is an average of 4 years from onset of bulimia nervosa symptoms to first treatment. In some instances, this delay can be 10 years or more.

While people struggling with bulimia nervosa may not reveal their true difficulties, other issues may be apparent, such as mood swings, anxiety, depression, sleep disturbances, fatigue or loss of libido. So what should friends and family be aware of that may indicate the presence of bulimia nervosa? And what factors can maintain bulimia nervosa and “keep it going”?

Signs of bulimia nervosa

Dieting is the most common precipitating factor for the development of bulimia nervosa. Individuals adopt strict food rules and diets that are rigid and difficult to maintain. Naturally, as the body is deprived of food and nutrition, it responds to the threat of future starvation by triggering an instinctive urge to eat. Individuals succumb to this urge and experience a short-lived period of uncontrolled eating.

They attempt to compensate for the calories consumed and regain self-control by purging or over-exercising, and vowing to adhere to their diet closer next time. This can create the binge-purge cycle since the diet plan cannot be sustained long-term and continually leads to binge eating episodes.

For some patients, food restriction can create a sense of control and binge eating may provide a temporary escape from painful feelings. Thus, these behaviours may be triggered by stressful or traumatic life events or feeling out of control in a particular life domain. Adolescents are at greater risk of developing symptoms of bulimia nervosa than adults, but like all eating disorders, it can develop at any age. While BN is more common in females than in males, it is not an exclusively female condition.

Patients with bulimia nervosa often maintain a body mass index (BMI) in the healthy or overweight range. However, frequent fluctuations in their weight may serve as a clue to their struggles.

Signs to suggest that they are purging via vomiting include erosion of dental enamel, swollen jaw or cheeks, bad breath, chronic sore throat, dehydration, and calluses or abrasions on knuckles from self-induced vomiting.

Laxative or diuretic abuse may cause constipation, bloating, water retention, stomach pain, and blood in the stool.

They may also sustain injuries caused by over-exercising such as stress fractures or chronic joint pain. They may exercise even when sick, exhausted or injured.

Maintaining factors

Food restriction is a maintaining factor of bulimia nervosa as it perpetuates the binge-purge cycle. Since food rules are strict and highly specific, minor dietary slips are perceived as failure in maintaining self-control. The “all or nothing” mindset leads patients to respond to rule-breaking by temporarily abandoning their dietary restraint and engaging in binge eating. The intense shame and guilt experienced in BN fuels the secrecy of the disorder and as well as self-punishment via compensatory measures.

Preoccupation with weight and shape in bulimia nervosa is maintained by frequent body checking (e.g. weighing, mirror use, measuring body parts) and/or body avoidance (e.g. avoiding looking at body, avoiding intimacy). Body image distortions are often in operation so patients make biased and inaccurate assessments of what their body looks like. Research has found that greater preoccupation with an unrealistic “thin ideal” can maintain the disorder for longer.

Other mental health issues such as depression, anxiety, or Borderline Personality Disorder may maintain the use of binge eating or compensatory strategies as a means to cope with painful feelings or to achieve a sense of “control”. Impaired thinking and poor judgment due to the effects of fasting can lead to confusion and further poor decision-making in regards to eating.

Our clinical psychologists have expertise in helping people address the problems which led to and perpetuate bulimia nervosa and related difficulties with food and weight.