A Misunderstood Diagnosis

I remember learning about bulimia in high school, and holding onto this image of a White female teenager who would run to the bathroom and make herself throw up after eating lunch in the cafeteria.  While this can be a specific case of bulimia, the symptoms and presentation of bulimia far extend this particular example. 

In fact, bulimia does not discriminate across genders (although females are more commonly affected) and while it tends to begin in adolescence or young adulthood, symptoms can show up earlier or later as well.  Bulimia is a result of many multifaceted factors, including genetic vulnerabilities, environment (such as abuse or pressures to be thin), and temperament (including depressive or anxious traits).  Individuals with bulimia can present with a diverse range of body sizes and shapes.  For a clearer picture of what bulimia entails, here are some indicative symptoms and warning signs:

Warning Signs and Symptoms

Binge eating.  One aspect of bulimia includes repeated instances of binge eating in a limited amount of time (i.e. 2 hours).  Each person may define a binge differently based on their regular eating vs. binge episodes.  According to the DSM-5, a binge is a distinct time period of eating a large amount of food – more than what the majority of individuals would eat “in a similar period of time under similar circumstances.” The binge can occur across various settings and include consumption of any types of food, although they usually include foods that the person tends to keep off limits.

Low perceived control around food.  Another aspect of a binge that occurs in bulimia is feeling that you cannot control how much or what you are eating. Some individuals feel like they are in a dissociative or trance-like state during such episodes.  The binge may stop once the person feels an uncomfortable or painful amount of fullness, or begins to feel sick. The person may have even given up trying to control their eating.

Compensatory behaviors.  A distinctive symptom that occurs in bulimia is the consistent use of “inappropriate” compensatory behaviors – behaviors used to prevent or counteract weight gain that could result from a binge.  One of these compensatory or “purge” behaviors includes self-induced vomiting, which people tend to consider a hallmark of bulimia.  However, in addition to vomiting, compensatory behaviors also include one or a combination of the following: misuse of laxatives, diuretics, and other medications (such as diet pills, illicit drugs, insulin, or stimulants), and fasting or restricting.  Excessive exercise, done during inappropriate times or settings and regardless of functional/physical impairment, is also a form of purging.

Emphasis on body image.  For someone with bulimia, their weight and body shape is an extremely important factor in how they feel about themselves.  They tend to experience high levels of body dissatisfaction.  Thus, weight gain can drastically reduce their self-esteem and weight loss can be very validating.

Other Associated Factors

Shame, secrecy, and social impairment.  Individuals with bulimia may feel embarrassed or ashamed of their eating behaviors; subsequently, they may engage in their binging and purging in secret and hide their symptoms from others. This may impair the person’s social functioning, as they may avoid certain social situations and isolate in order to engage in their behaviors, or as a result of poor body image.

Emotional dysregulation.  The behaviors involved in bulimia are commonly preceded by negative emotions (sadness, boredom, anxiety, and fear) or other stressors including interpersonal issues, trauma, and poor body image.  Individuals with bulimia tend to struggle with other mental health concerns, which can occur before, after, or during the course of bulimia; these include mood, anxiety, substance use, and personality disorders. Moreover, individuals with bulimia exhibit an elevated suicide risk. Such disordered behaviors are often used to help alleviate, avoid, or numb unwanted feelings temporarily, but only to induce further negative emotions afterwards.

Physical consequences.  Various health concerns may result from bulimia behaviors.  Women may experience an absence or irregularity in menstruation.  Individuals with bulimia may suffer from nutritional deficiencies, dental issues, fluid and electrolyte imbalances, gastrointestinal issues, and cardiac or skeletal abnormalities. These, as well as the mental health consequences of bulimia, contribute to an overall elevated mortality risk for individuals with bulimia.

Whether or not you exhibit some or all of these symptoms and associated factors of bulimia, and regardless of their frequency and intensity, you deserve to seek help and recover.  The most important factor to consider is your quality of life – consider whether your bulimic behaviors are interfering with your ability to physically and mentally function, thrive, engage in healthy relationships, and meet your goals.