Bulimia nervosa (BN) is a serious eating disorder characterized by a destructive pattern of eating and purging to control weight. It's more than just bingeing (eating a lot of food) and purging (self-induced vomiting); it takes a tremendous emotional toll and can lead to severe, even life-threatening, conditions. While it can affect anyone, females have a fivefold higher risk of developing the condition. The lifetime prevalence rate is about 1%. Behind closed doors, millions of people silently battle cycles of bingeing and purging that chip away at them in both body and mind. Bulimia nervosa is an eating disorder that thrives in secrecy and is fueled by shame. Without treatment, bulimia can cause serious long-term damage to the physical body and emotional and psychological well-being. Bulimia nervosa is an eating disorder marked by repeated episodes of eating large amounts of food (bingeing) followed by behaviors to “undo” any weight gain from the calories consumed, a behavior known as purging. People with bulimia often feel trapped in an exhausting cycle of secrecy and guilt. Bulimia can harm nearly every system in the body if left untreated.
When you think of bulimia, you’re most likely to think of bingeing and purging. However, these aren’t the only symptoms of the disorder. Bulimia can present itself through various symptoms, including mental stress, continuous bingeing and purging which puts great strain on the body. Unlike anorexia, another type of eating disorder, bulimia doesn’t necessarily have symptoms of significant weight loss. But the effects are still very real.
While characterized as an eating disorder, bulimia is also a mental health disorder that causes a cycle of health concerns. You may experience depression, anxiety, or obsessive-compulsive behaviors. Moodiness and irritability may occur due to lack of vitamins or behaviors that come along with bulimia. For example, constant monitoring of food and weight can become an obsession. Someone may also binge in secret and then hide evidence of food and laxatives. In order to achieve their ideal weight, people may also engage in substance abuse.
Compulsive exercising or preoccupation with appearance are also common symptoms. It’s not unusual for someone with bulimia to spend a lot of time thinking about food and how to control it. In fact, people with bulimia may become quite focused on eating to the exclusion of other activities that they used to enjoy.
Having to keep secrets contributes to the cycle of stress and anxiety. Over time, guilt can build up from keeping secrets from your friends and loved ones. This may also be accompanied by feelings of embarrassment and shame. Suicidal behavior may form as a culmination of the stress and extreme unhealthy body image.
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The specific side effects of bulimia nervosa someone experiences depend on a number of factors, including age and overall health. These methods will have different impacts on physical health, both in the short- and long-term. The binge/purge cycle and the dangers of specific purging methods put an undue amount of stress on the body. In the most serious cases, BN can lead to congestive heart failure and sudden death. There is some good news. A majority of physical symptoms caused by BN abate as binging and purging behavior is reduced. One exception is swollen parotid glands. Damage to teeth can be permanent, and serious enamel erosion and related issues will likely require medical intervention. Still, to minimize the chance of lasting or even fatal damage, it’s important to seek treatment as soon as possible.
Initial Gastrointestinal Distress
One of the first and most common symptoms of bulimia nervosa is gastrointestinal (GI) distress. Patients who utilize self-induced vomiting may experience additional complications, many of which are related to stomach acid repeatedly entering the esophagus and the physical strains involved in self-induced vomiting.
A sore throat, stomach pain, or both may be the first obvious physical side effects of bulimia. As the disorder progresses, chronic self-induced vomiting can cause a variety of symptoms in the digestive tract, beginning at the mouth. Over time, the high acid content of vomit can damage teeth and cause enamel erosion, tooth sensitivity, and gum disease. Puffy cheeks or jaws may be noticed secondary to swollen salivary glands.
Acid can also:
- Irritate or tear your esophagus
- Rupture your esophagus and cause blood in vomit
- Irritate your stomach
- Cause stomachaches, heartburn, and acid reflux
- Damage the intestines and cause bloating, diarrhea, or constipation
Putting a finger down your own throat is one of the most common ways people with bulimia induce vomiting. Doing this over and over can cause callouses on the back of your hand (in the knuckle area) because of your knuckles coming in contact with your incisors. This phenomenon is known as Russell’s sign. The acidity scars the skin on your fingers and hands.
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Complications from Purging Methods
Another way that some people try to rid the body of excessive calories from food is to use diuretics, diet pills, or laxatives. Overuse of these products can make it difficult to have a bowel movement without using them. Misdirected use of diuretics may also damage the kidneys. Over-strained bowel movements can also result in hemorrhoids.
Frequent purging can cause dehydration. This leads to weak muscles and extreme fatigue. It can also throw your electrolytes out of balance and put strain on your heart. This can cause an irregular heartbeat (arrhythmia), and in some severe cases, a weakened heart muscle and heart failure. The electrolytes that tend to go missing from constant vomiting are potassium, magnesium, and sodium.
Bulimia can cause low blood pressure, a weak pulse, and anemia. Vomiting can be a violent event. The sheer force of it can even cause the blood vessels in your eyes to rupture.
Overuse of laxatives can also bring on additional issues over time. Hypokalemia, or low potassium levels, is common and can cause many unpleasant and potentially serious side effects. Those who utilize fasting may also experience complications, depending on how long and how stringently they reduce their food intake.
The Impact of Excessive Exercise and Fasting
In the short term, excessive exercise may also cause issues, especially a heightened risk of injury, swelling, or exhaustion. As someone continues to engage in cycles of binge eating and purging, they place more strain on their internal systems and may begin to experience more serious physical side effects.
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Mental and Emotional Effects
In addition to the physical manifestations, bulimia also has significant short-term mental and emotional effects.
- The shame and secrecy that come with bulimia often fuel severe anxiety and depression.
- Hiding bingeing and purging behaviors can cause intense loneliness.
Effects on the Integumentary System
The integumentary system includes your hair, skin, and nails. These parts of your body aren’t immune to the effects of bulimia, either. Dehydration from frequent vomiting means that your body doesn’t have enough water. In turn, your hair can become dry and frizzy. You may even experience hair loss.
Dry skin and nails are also a long-term side effect of bulimia.
Long-Term Health Risks
While most complications of bulimia nervosa resolve with cessation of purging, it can cause various long-term health problems, such as dental erosion, gastroesophageal reflux disease and coronary heart disease. Although these conditions aren't reversible, it is never too late to seek treatment for them or an eating disorder. The most common complication of bulimia nervosa is dental erosion, also known as perimylosis. Self-induced vomiting and repeated exposure to stomach acid can cause dental erosion, leading to brittle and weak teeth. Early identification and treatment can often help reverse the damage caused by GERD. Atherosclerosis can also contribute to the development of coronary heart disease (CHD), also called ischemic heart disease or coronary artery disease (CAD). CAD is a narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart. CAD develops gradually and slowly reduces the amount of blood that can reach the heart. If left untreated, patients may eventually need surgery to fix blocked coronary arteries, such as coronary angioplasty. Barrett’s esophagus puts patients at an increased risk of developing esophageal adenocarcinoma (EAC), a serious and often deadly cancer.
It’s never too late to get help for bulimia nervosa. Even in severe or extreme cases, medical stabilization and nutritional support can reduce complications and reverse many of the effects of malnutrition. No matter how long you’ve been struggling, recovery is possible.
Comorbidity
Bulimia often occurs alongside other mental health conditions. This is known as comorbidity, where two conditions occur at the same time.
The National Institute of Mental Health notes that 94.5% of people living with bulimia also met the criteria for at least one other mental health condition. Additionally, the organization noted that the following percentages of people living with bulimia also met the criteria for other disorders. These included:
- 80.6% for anxiety disorders
- 70.7% for mood disorders
- 63.8% for impulsivity disorders
- 36.8% for substance use disorders
Therefore, someone with bulimia may need additional screening and treatment for different mental health conditions. The Office of Women’s Health also points out that bulimia often occurs in people whose self-esteem links to their physical appearance. Psychotherapy is a common course of treatment for bulimia that may help address issues of self-esteem.
Impact on the Circulatory System
When a person vomits, they reduce the amount of electrolytes in their body - these play an important role in regulating the heartbeat. The loss and imbalance of electrolytes can lead to an irregular heartbeat and heart failure. In addition, reducing the calories the body consumes can lead to the breakdown of muscles and other tissues within the body, including the heart. This can lead to the person’s heart rate and blood pressure dropping, which increases the risk of heart failure. Complications to the circulatory system can be life threatening. Living with bulimia can also reduce the number of red and white blood cells in the blood. A lack of red blood cells can lead to anemia, which causes fatigue, shortness of breath, and general weakness.
Additionally, the loss of white blood cells can lead to the increased risk and severity of infections.
Impact on the Digestive System
The digestive system includes the mouth, throat, stomach, intestines, and several other supporting glands and tissues. Bulimia can lead to several issues throughout the digestive system, including:
- The formation of ulcers in the mouth and throat
- Damage to the stomach from overeating
- Tooth decay from vomiting
- Damage to the intestines with laxative use
- Issues with bowel movements
In addition, it can lead to other issues, such as:
- Slowed digestion
- Esophagus (food pipe) or stomach rupture, which are life threatening conditions
- The development of pancreatitis or swelling of the pancreas
- Intestinal infections, blockages, or perforations
Impact on the Urinary System
Prolonged lack of nutrients can lead to kidney failure.
Impact on the Endocrine System
Over time, bulimia can lead to insulin resistance. Insulin helps process blood sugars into useful energy. This increases a person’s risk of developing type 2 diabetes.
A person creates sex hormones and other hormones using consumed fat and cholesterol. When a person does not get enough of these nutrients, the amount of testosterone and estrogen in their body reduces. In people with menstrual cycles, this can lead to issues, including:
- The inability to start menstruation
- Irregular cycles
- Stopping menstruation altogether
It may also lead to the ovaries not releasing an egg every month, making it more difficult to become pregnant. Living with bulimia during pregnancy can also lead to issues with the pregnancy, which can include:
- Pregnancy loss
- Delivery by cesarean section
- Premature birth
- Birth abnormalities
- Postpartum depression
- Low birth weight
Once menstrual cycles return to a person’s typical stages, the individual may be able to become pregnant. However, it may take longer - an average of about 6 months to a year. The loss of sexual hormones can also lead to accelerated bone loss and conditions such as osteoporosis. Reduced bone density relating to osteoporosis increases the risk of fractures and other health complications.
Types of Bulimia
There are two types based on the ways you may try to clear food from your system or reduce weight gain:
- Purging. You may make yourself vomit, use laxatives, diuretics, enemas or other medicines to remove food from your body.
- Nonpurging. You may over-exercise or fast (not eat) in a way that interferes with your daily routine or general health.
Symptoms of Bulimia Nervosa
Symptoms of bulimia include:
- Eating large amounts of food in one sitting (binging)
- Getting rid of the food you just ate by purging
- A fear of gaining weight and a willingness to do whatever it takes to lose weight
- A loss of control when it comes to eating
- Low self-esteem and low self-worth
- Shame or guilt after eating
- Depression, anxiety, extreme mood swings or substance use
- Fainting
- Constipation
- Irregular menstrual periods
- Muscle weakness
- Bloodshot eyes
- Facial swelling (chipmunk cheeks)
This condition can look different for each person. For example, you might not eat a large amount of food before purging. Sometimes, any amount of food can trigger negative feelings that may make you want to purge. The method for purging may also vary.
Risk Factors of Bulimia
Bulimia nervosa can affect anyone. You’re more at risk of the condition if you’re:
- An adolescent or young adult
- Biologically related to someone diagnosed with an eating disorder
- Diagnosed with a mental health condition like anxiety or depression
- Female
Complications of Bulimia
This eating disorder comes with many health risks. These are dangerous and many can be life-threatening. Complications may include:
- Abnormal heart rhythm (arrhythmia)
- Damage to your intestines and stomach
- Dental issues (tooth erosion, translucent teeth or decay)
- Esophagus inflammation (esophagitis) and tears
- GERD
- Heart failure
- Irritable bowel syndrome (IBS)
- Increased risk of suicide
- Malnutrition and dehydration
- Swollen cheeks
- Throat and stomach ulcers
- Type 2 diabetes
Treating bulimia early may prevent complications and any long-term effects that the condition may cause.
Management and Treatment
A healthcare provider may recommend the following treatment options:
- Therapy. Cognitive behavioral therapy is a type of talk therapy. You’ll meet with a therapist and set goals to adjust how your thoughts affect your behaviors.
- Nutritional counseling. You’ll work with a registered dietitian or counselor to build a healthier relationship with the foods you eat.
- Medication. Selective serotonin reuptake inhibitors are a type of antidepressant. They may reduce binge eating and vomiting episodes. They may also treat anxiety and depression.
- Support groups. Support groups can be a helpful addition to other treatments. Connecting with others who share similar experiences may be beneficial to your recovery.
There isn’t one treatment that works best for everyone. You may need to try different techniques or paths to reach your goals.
Recovery and Outlook
Recovery is possible. It takes time to get there. Your healthcare providers will work with you to create a treatment plan that’s right for you and your symptoms. Your therapist will help you set realistic goals and work with you to achieve them.
It’s important to know that relapses are possible. A relapse is when you go back to unhealthy behaviors after a period of practicing healthy ones. It’ll be easy to see a relapse as a failure, but it’s not a judgment of who you are. Recovery is challenging and hard work. But remember, you’re never alone. Your care team can help you get back on track. They’ll make adjustments to your treatment plan as needed.
If untreated, you may develop serious, often life-threatening complications. It’s important to seek treatment if you haven’t already.