Bulimia Nervosa (BN)

What is Bulimia Nervosa?

Bulimia nervosa is a pattern of disordered eating behaviors characterized by a cycle of:

1. restricting calories due to concerns about weight,
2. bingeing due to prior food restrictions, and
3. purging episodes

A person with bulimia nervosa engages in frequent episodes of binge eating, recurrent inappropriate compensatory behaviors as a means to prevent weight gain, and self-assessment that is unjustifiably based on body shape and weight. (8)

People who struggle with an eating disorder like bulimia nervosa express intense dissatisfaction with their bodies, believing they are overweight when they are clinically underweight. 

Classic symptoms include a restrictive attitude about food and inadequate nourishment of the body. Patients with bulimia nervosa engage in purging and non-purging compensatory behaviors, such as self-induced vomiting, prolonged bouts of exercise, or other behaviors meant to “undo” episodes of overeating.

Purging Compensatory Behaviors

• Self-induced vomiting 
• Laxative use
• Diuretic use
• Enema use

Non-purging Compensatory Behaviors

• Excessive exercising
• Severe food restriction
• Use of stimulants or diet pills

Diagnosing Bulimia Nervosa

Distinguishing bulimia nervosa from other eating disorder subtypes requires an exam by a healthcare professional. A physical exam by a medical professional is also crucial due to the potentially devastating medical consequences of bulimia nervosa. 

The physician will assess behavioral, psychological, and physical factors during the exam, such as eating behaviors, compensatory mechanisms used, and frequency of episodes.

According to the DSM-5, bulimia nervosa is diagnosed using the following criteria: (8) 

1. Recurrent binge eating episodes with both of the following features:

1. Eating larger amounts of food than what most individuals would normally eat within a two hour period 
2. Feeling out of control when eating

1. Use of compensatory behaviors to prevent weight gain, at least once a week for three months
2. Inaccurate self-assessment of weight and body image

In addition to the primary criteria, the severity of Bulimia nervosa is determined by the frequency of behaviors:

• Mild: 1 to 3 purging episodes per week
• Moderate: 4 to 7 purging episodes per week
• Severe: 8 to 13 purging episodes per week
• Extreme: 14 or more purging episodes per week

Signs & Symptoms of Bulimia Nervosa

Due to complex emotions and shame, patients experiencing eating disorders may find it difficult to share their behaviors with others. This can lead to people hiding their symptoms, making bulimia nervosa particularly difficult to recognize. 

Forming a therapeutic alliance and maintaining a non-judgmental therapeutic stance is crucial to the healing process. If you suspect a loved one may be struggling with bulimia nervosa, here are some telltale signs to look for: (6)

• An obsessive focus on body weight, shape, and size
• Finding hidden food wrappers and containers 
• Wearing baggy clothes to disguise weight loss
• Skipping meals
• Bruising or calluses on knuckles from repeated self-induced vomiting
• Avoiding social gatherings where food is served and eating in public
• Fainting spells and dizziness
• Swelling of cheeks or jaws
• Eating an excessively large amount of food in one sitting
• Using compensatory mechanisms to “undo” the effects of overeating

Effects of Bulimia Nervosa

Many effects of bulimia nervosa overlap with other types of eating disorders, but there are some distinct side effects of bulimia nervosa.

Short-Term Effects

Although the early effects of BN are often subtle, they are not trivial. Left untreated, they can lead to much more serious health consequences. 

Short-term effects of bulimia nervosa:

• Dental enamel erosion & cavities
• Gum disease
• Electrolyte imbalances
• Facial swelling and puffy face
• Heartburn/Reflux (GERD) 
• Fatigue 
• Throat soreness 

Long-Term Effects

When food restriction and compensatory behaviors persist, the risks of more serious – and sometimes permanent – damage occurs.

Long-term effects of bulimia nervosa:

• Esophageal tearing 
• Esophageal scarring and strictures
• Difficulty swallowing (dysphagia)
• Bone density loss (osteoporosis)
• Enlarged glands in the neck
• Loss of muscle mass (cachexia)
• Thin or brittle hair 
• Fine hair growth (lanugo)
• Severe constipation
• Irregular or absent menstrual cycles in women (amenorrhea)
• Low blood pressure
• Irregular heart rhythms and permanent heart damage
• High sensitivity to cold temperatures
• Fatigue 
• Reduced immune function
• Infertility
• Cognitive impairment
• Death, if untreated

Related Disorders

Bulimia nervosa rarely occurs in isolation and is associated with other mental health disorders as well.

Conditions that frequently coexist with bulimia nervosa include the following: 

• Body dysmorphic disorder
• Anxiety disorder
• Depression
• Borderline Personality Disorder
• Self-harm (cutting, etc.)
• Addiction disorders
• Food insecurity 
• Post-traumatic stress disorder (PTSD)
• Mood disorders
• Obsessive compulsive disorder (OCD) 

Treatment of Bulimia Nervosa

Treatment options for bulimia nervosa depend on the severity and type of compensatory mechanisms involved. 

Multidisciplinary care teams have become the gold standard for the treatment of eating disorders. This comprehensive treatment approach enlists evidence-based standards to ensure nutritional imbalances, related medical conditions, and psychosocial elements are adequately addressed to produce the best possible outcomes. 

Therapies for Bulimia Nervosa

While hospitalization and outpatient therapy are necessary in some cases, the two most common treatments for bulimia nervosa include the following therapies: 

• Cognitive Behavioral Therapy (CBT): Therapist-led CBT is a particularly effective treatment for patients with BN. (2)

• Intensive Outpatient (IOP): IOP treatment for BN is best for patients who have a supportive home environment but still value a bit of clinic care and structure. Patients will typically attend a clinical setting a few days per week for treatment, while maintaining treatment protocols at home for the rest of the week. 
• Partial Hospitalization (PHP): Patients with BN who need more structure than IOP should seek out PHP which involves speaking four or more days per week at a hospital or clinical treatment program. 
• Residential Treatment: For patients looking for more hands on care, or for those who don’t have an adequate home environment for healing should try residential treatment for bulimia nervosa. Here they will receive 24-hour oversight, as well as a place to live while receiving treatment.    
• Inpatient Hospitalization: Patients with bulimia nervosa who are at risk of suicide or struggling with major psychological disorders, such as depression, may require an inpatient hospitalization program. Inpatient hospitalization provides 24/7 medical oversight and care. 
• Group Therapy: Attending group therapy sessions for bulimia nervosa is highly recommended, as it can be therapeutic to talk to other people with the same disorder. Group therapy should be attended in addition to other forms of treatment. 

Medications for Bulimia Nervosa

Some patients with bulimia nervosa respond well to medication. These BN medications repair neurobiological pathways that impact mood, executive functioning, anxiety, and other variables contributing to their suffering. The following medications are prescribed in some cases:

• Approved in 1994, Fluoxetine hydrochloride (Prozac, Sarafem, Rapiflux, Selfemra) is a selective serotonin reuptake inhibitor that effectively reduces binge-eating and vomiting episodes. (7)

Understanding Bulimia Nervosa

Patients with bulimia nervosa have a struggle around the pursuit of thinness, and a preoccupation with body size. They are often very restrictive in their eating patterns, which eventually leading patients with BN to engage in compensatory behaviors like self-induced vomiting, the use of laxatives, or extreme levels of exercise. 

While the cause of bulimia nervosa is not clear, strong evidence suggests that a genetic component plays a significant role. For example, individuals with parents with an eating disorder are more likely to exhibit disordered eating behaviors. (8)

Risk factors for bulimia nervosa:

• Genetics. Researchers now believe genes may be an independent risk factor for developing eating disorders.
• Abuse. Traumatic life experiences, such as sexual assault and physical or emotional abuse, are also linked to eating disorders. 
• Psychological Influence: Children can become preoccupied with body size and shape from a young age, leading to disordered eating. 
• Environment. Disordered eating behaviors are also tied to environmental factors, such as living or working in spaces that focus on weight or dieting. For example, athletes face immense pressure in their environments to change their body size. 
• Cultural Norms. Mainstream media messaging that idealizes thinness is thought to promote unhealthy eating behaviors and body image standards.

Living with Bulimia Nervosa 

For those living with bulimia, weight and body image are the primary criteria used to measure self-worth. Any deviation from their self-imposed ideal, no matter how unrealistic, warrants a correction of behavior to induce weight loss.

Coping with Bulimia Nervosa

Patients with eating disorders benefit from understanding the origin of their disordered eating behaviors, the role of restriction in binge eating, and the relationship between mind and body.

Self-care, a multidisciplinary team with specialized training in treating eating disorders, and supportive friends and family are vital for successful outcomes. 

Within Health offers comprehensive treatment programs that focus on each patient’s unique needs to ensure that a full recovery is possible. 

History of Bulimia Nervosa 

In 1979, a British physician named Gerald Russell recorded the first notes about bulimia nervosa, describing it as a phase of anorexia nervosa. (4) Today, experts recognize BN as a separate disorder in the DSM-5 that requires different forms of treatment. 

Bulimia Nervosa in Pop Culture

Cultural influences contribute to the development of eating disorders like bulimia as well.

Unrealistic body size standards within the fashion and beauty industry, the idealization of thinness on social media platforms, and the unrelenting marketing and advertising of diet-related products and services on television celebrate small bodies. (5)

In the movie Black Swan, which portrays a dancer who struggles with bulimia, the Hollywood actors lost an extreme amount of weight for the film. This weight loss highlighted the reality that performers and entertainers are encouraged to hold unrealistic expectations of their body size and shape. Natalie Portman was even celebrated for her rapid weight loss and rewarded an Oscar for the role, despite the health risks she put her body through.

The glamorization of thinness and the romanticizing of dieting have left many people with eating disorders feeling even more out of alignment with their bodies.

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If you or someone you love is struggling with bulimia nervosa, don’t delay treatment. The earlier a patient with an eating disorder enters treatment, the better their chances of a positive outcome.

Within Health offers inclusive eating disorder treatment for people of all shapes, sizes, colors, and orientations. Call our admissions team to learn how our treatment milieu can help you heal from bulimia nervosa.