The following article discusses some signs and symptoms that are associated with the eating disorder bulimia nervosa and with substance-abuse or addiction.

This article is not intended to be used as a diagnostic or treatment tool, but is intended to educate individuals regarding the potential signs, symptoms, and treatment options for these serious disorders. Any formal diagnoses of any mental health disorder or the implementation of any treatment program for a mental health disorder should only be undertaken by a licensed mental health professional.

Bulimia Nervosa

bulimia Bulimia nervosa, most commonly referred to as bulimia, is an eating disorder that consists of a series of cycles of binge eating followed by compensatory behaviors designed to eliminate the ingested food.  These compensatory behaviors may range from self-induced vomiting to a number of other behaviors.

Eating disorders are characterized by repetitive disruptions of eating that are typified by alterations of one’s food consumption or attempts to alter the process of the digestion of food eaten. In order for the behavior to be defined as disordered, it must be repetitive and must affect areas of the person’s daily functioning, such as health (or be potentially hazardous to one’s health), occupation, relationships, etc.

The Symptoms of Bulimia 

In order for people to be diagnosed with bulimia, they must satisfy the following diagnostic criteria:

  • Display repetitive binge eating episodes, which can consist of:
    • eating extremely large amounts of food in a specific time period (larger than most individuals would eat in a similar period of time and under the same circumstances) and/or
    • feeling that they lack control over these eating episodes, such that they are unable to stop eating.
  • Engage in repetitive behaviors that are designed to compensate for potential weight gain as a result of their binging episodes, such as:
    • self-induced vomiting
    • abuse of laxatives
    • use of other medications to purge
    • excessive exercise
    • fasting
  • Bingeing and compensatory behaviors occur at least on average of once a week for a total minimum period of three months
  • No diagnosis of anorexia
  • Self-worth or self-evaluation is based on weight or body size

 
Bulimia is differentiated from the other major eating disorders that occur in adolescence and adults by the above diagnostic criteria. For example, individuals diagnosed with anorexia may also binge and purge; however, these individuals have a unhealthy amount of weight loss and a distorted self-image regarding their body size (people with anorexia nervosa can be painfully thin and still see themselves as being too heavy), whereas an individual diagnosed with bulimia does not display the unhealthy weight loss and does not display the same distorted body image.


Bulimia is differentiated from binge eating disorder by the use of compensatory strategies to eliminate the food one has eaten and to avoid gaining weight.


Individuals diagnosed with binge eating disorder do not display these compensatory behaviors on a regular basis.

Severity of Bulimia 

severity of bulimia The American Psychiatric Association has established the diagnostic scheme to determine the severity of an individual’s bulimia. Severity is based on the number of inappropriate compensatory behaviors an individual engages in (specifically, the average of compensatory behaviors performed on a weekly basis):

  • Mild bulimia nervosa is characterized by an average of 1-3 compensatory behaviors per week.
  • Moderate bulimia nervosa is characterized by an average of 4-7 compensatory behaviors during a week.
  • Severe bulimia nervosa is defined as an average of 8-13 compensatory behaviors per week.
  • Extreme bulimia nervosa is characterized by an average of 14 or more compensatory behaviors per week.

While a clinician may characterize a person’s eating disorder as being mild to extreme, this does not indicate that someone with “mild bulimia” does not have an extreme or serious issue. These clinical designations are designed to help structure appropriate treatment programs for the individual and to better understand how the disordered behavior works within the needs and compensatory strategies for the person. Please understand that any person who has bulimia is suffering from a very serious eating disorder.

How Common Is Bulimia?

According to the American Psychiatric Association, bulimia occurs in about 1-1.5 percent of young females. The disorder appears to be diagnosed most often in older adolescent females or young adult females. Bulimia nervosa is far more common in females than males and diagnosed at a 10:1 ratio of females to males. It is uncommon for bulimia nervosa to be diagnosed in females older than the age of 40; however, it does occur.


The binge eating associated with bulimia frequently occurs after the person has been trying to lose weight or diet, and it may also be associated with stress.  There is an increased risk of medical complications or even death for individuals with any eating disorder.


Health Complications 

There are a number of health issues that are associated with individuals who are diagnosed with bulimia. The severity of one’s binging/purging episodes will contribute to the particular health complications that may occur. The following health concerns are associated with bulimia:

  • The cycle of binging and purging can lead to electrolyte imbalances in the body.
  • There is increased potential for problems with the esophagus due to frequent vomiting.
  • Tooth decay is a result of stomach acid being released into the mouth.
  • Gastrointestinal issues often result from vomiting or laxative abuse.
  • There is increased potential for gastric or esophageal ruptures.
  • Possible cardiovascular issues may occur due to chemical balances and electrolyte imbalances.

According to the American Psychiatric Association, the risk of suicide is increased with a diagnosis of bulimia, so suicide risk should be assessed if someone is suspected of having bulimia. There are other mental health disorders that are commonly comorbid with bulimia (comorbid refers to two disorders that occur at the same time in the same person):

  • Depressive symptoms
  • Anxiety
  • Bipolar disorder
  • High rates of substance abuse (especially alcohol abuse or abuse of stimulants)
  • Increased potential for personality disorders

Symptoms of depression or anxiety may occur at any stage of bulimia development (before, during, or even after the symptoms of bulimia occur). Stimulant abuse among people with bulimia often occurs as an attempt to control appetite and weight, whereas alcohol abuse may occur more frequently as an attempt to cope with stress related to issues associated with bulimia. Clinicians refer to this latter issue as avoidance–based coping, meaning that some substance abuse among individuals who have eating disorders, or other forms of mental health disorders, occurs as a result of attempting to cope with stress.


The attempt to cope with stress related to a mental disorder by using drugs or alcohol typically results in a spiraling effect where the individual begins to abuse substances and eventually may even develop addictive behaviors.


What Types of Behaviors Indicate a Person Has Bulimia and/or a Substance Abuse Issue?

Some signs that suggest a person might have an issue with bulimia include the following:

  • Signs of binge eating, such as the disappearance of fairly large amounts of food over a short time period or finding empty containers that suggest the person has eaten a large amount of food over short period
  • Frequent trips to the bathroom during or after meals
  • Hiding behaviors associated with use of the bathroom, such as using mints, running the water while in the bathroom, etc.
  • Obvious signs of purging, such as finding evidence of vomiting, laxative use, etc.
  • Attitudes and/or behaviors that point to the notion that weight loss, dieting, and controlling food intake are primary concerns
  • Teeth discoloration
  • Swelling in the jaw or cheeks
  • Calluses on the knuckles (may be a sign of self-induced vomiting)
  • An exercise program that appears to be excessive
  • Consistently exercising when the weather or a situation is not conducive to exercising (e.g., jogging in a blizzard)
  • Continuing to exercise despite injuries or illnesses that would result in most people toning down their exercise habits
  • Withdrawing from friends and activities
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    Weighing the particular situation is important when using the above signs as guidelines to determine if a person may be struggling with bulimia. For example, a person who is a professional athlete may exhibit behaviors regarding exercise and weight that are considered extreme for most other people, but are not extreme in the context of the individual’s athletic endeavors. In addition, while these are signs and indicators of a potential eating disorder, only a certified mental health professional can diagnose any eating disorder. Therefore, as stated at the beginning of the article, it is important to seek competent professional assistance if you suspect someone has an eating disorder or other mental health disorder.

    Some potential indicators of an issue with alcohol or drug abuse include:

    • Frequent drinking behaviors, the use of prescription medications (stimulants) outside of the prescription’s parameters, or the use of other drugs
    • Using alcohol or drugs in secret or hiding evidence associated with alcohol or drug use
    • Doctor shopping to get multiple prescriptions
    • Failure to maintain important obligations as a result of alcohol or drug use, which result in issues at school, at work, or with personal relationships.
    • Being extremely defensive about one’s use of drugs or alcohol
    • Spending a lot of time either recovering from alcohol or drug use, using alcohol or drugs, or trying to buy drugs or alcohol
    • Being intoxicated or under the influence of drugs in situations where it is inappropriate, such as at work, school, social functions, etc.

How to Help Someone 

helping a loved one If a person is suspected of having bulimia as well as an issue with substance abuse, it is preferable to have the two co-occurring issues treated at the same time, as these are issues of each disorder that interplay with one another and may exacerbate one another. As with any type of health issue, the earlier one can identify the problem, the more successful the treatment or intervention will be.

As stated, it is best to find a competent mental health professional to assess the person who is suspected of having any type of eating disorder and/or substance abuse issue. Individuals who attempt to deal with these issues on their own are often unable to objectively look at their situation and evaluate it, decide on a solid and practical strategy to approach the issue, and implement a successful recovery program.

In some instances, loved ones may stage an intervention and talk to the affected individual as a team. It’s recommended that a professional interventionist structure the event, to ensure the best chances of the individual seeking treatment after the conversation.

Recovery from Bulimia and Addiction

As with all co-occurring disorders, it’s imperative that those seeking treatment for bulimia and addiction seek care at a facility that is equipped to treat both disorders. With comprehensive care that addresses both conditions, individuals can stabilize physically and mentally, and go on to live healthy lives in recovery.