Signs and symptoms of atypical bulimia nervosa

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The signs and symptoms of atypical bulimia nervosa (ABN) are similar to those of bulimia nervosa (BN). However, their severity and frequency can vary. (1) Even though ABN doesn’t meet all the criteria for a BN diagnosis, the long-term consequences are just as severe.

ABN can seriously affect a person’s life, challenging their ability to cope with negative thoughts and emotional distress. ABN may also significantly impact an individual’s mood, causing them to engage in behaviors that may jeopardize their physical and mental health.

Understanding the physical and behavioral signs and symptoms of atypical bulimia nervosa may help you recognize them in yourself or provide support to a loved one you believe may be struggling.

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Signs of atypical bulimia nervosa

Physical signs of atypical bulimia nervosa

Weight fluctuations

While people with atypical bulimia nervosa (ABN) don’t usually have the severe weight loss associated with bulimia nervosa, weight may still fluctuate. These fluctuations are commonly the result of re-hydration and fluid shifting caused by purging behaviors. (2) 

Dehydration and fluid loss from purging and diuretic use can result in initial weight loss. However, this type of weight loss is usually temporary, reversed when the body rehydrates.

Tooth decay

Even though binge/purging episodes are usually not as prolonged in someone with ABN, there can still be significant damage to the teeth. Stomach acids within vomit are corrosive enough to wear away tooth enamel, resulting in stained and brittle teeth following repeated purging.

Furthermore, brushing the teeth too hard following a purging episode can cause tooth decay, sensitivity, and weakness to get worse over time. (3) ABN can also result in issues with puffy jaws and cheeks, due to swollen salivary glands. (4)

Digestive tract issues

The stomach acid in vomit doesn’t just cause damage to the teeth. It can also result in tears in or ruptures of the esophagus. This is painful and can lead to blood in the vomit, which can be very distressing. (4)

Those with ABN, who purge through excessive laxative use, can experience painful hemorrhoids as a result of straining during bowel movements. (4)

Hair, skin, and nail problems

Binging, purging, fasting, and using laxatives and diuretics can have numerous effects on the hair, skin, and nails, due to nutritional imbalances and dehydration. They include: (5)

  • Abnormally dry skin or membranes
  • Lanugo-like body hair
  • Hyperpigmentation
  • Acne
  • Discoloration of the extremities due to poor circulation
  • Dry and brittle hair and nails
  • Infections around the nails and cuticles
  • Slow wound healing

One of the most characteristic signs of ABN and purging behavior is Russell’s sign, which is calluses on the knuckles and small cuts on the back of the hand. They are caused by repeated contact of the fingers on the teeth during self-induced vomiting episodes. (5)

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Emotional and behavioral signs of atypical bulimia nervosa

Irregular binging episodes

To meet the diagnostic criteria for ABN there are fewer binge-eating episodes than those with bulimia nervosa exhibit. People with ABN still engage in binge/purge eating behaviors, but they occur at irregular intervals, with episodes being weeks or months apart. (1)

Compensatory behaviors

Along with purging after binge episodes, people with ABN will engage in other compensatory behaviors to avoid gaining weight. These can include fasting, excessive exercise, and laxative and diuretic use.

Unusual food rituals

Those with atypical bulimia nervosa may try to hide their condition, as they feel shame over their actions. However, certain rituals around food may develop. Some food-related behaviors to watch out for include, but are not limited to: (2)

  • Preferring to eat alone or in the privacy of their bedroom
  • Eating more than normal over a period of a few hours
  • Disappearing after meals
  • Irritability when asking about or discussing food
  • Avoiding social occasions involving food

Mental health issues

The negative thoughts and behaviors associated with ABN can exacerbate or contribute to the development of other mental health conditions. This may lead to an increase in suicidal ideation, depression, anxiety, self-harm, or substance use. (1)

Symptoms of atypical bulimia nervosa

Physical symptoms of atypical bulimia nervosa

Gastrointestinal complaints

The binge/purge cycle of ABN, although it occurs less frequently, can still result in numerous gastrointestinal complaints. These include feeling overly full or bloated, abdominal pain, belching, acid reflux, heartburn, and nausea without an obvious cause. (6)

In the long-term, those suffering from ABN may develop the symptoms of irritable bowel syndrome, experiencing constipation, diarrhea, chronic lower abdomen pain, and feelings of anal blockage. (7) 

Fatigue

The binge/purge cycle and use of diuretics often seen in people with ABN can cause dehydration. This results in weak muscles and extreme fatigue. (4)

Binging also frequently involves ingesting a large quantity of high-fat and high-sugar foods. Ingesting such huge quantities of calories over a short period of time requires a significant amount of energy to digest, contributing further to feelings of fatigue.

Emotional and behavioral symptoms of atypical bulimia nervosa

Distorted body image

People with atypical bulimia nervosa often have a poor self-image, believing that they are bigger than they are. You may notice someone has started wearing baggy clothes in an attempt to hide their body, which could also be a sign that they’re suffering from body dysmorphic disorder, as well as ABN.

However, not all those with ABN experience the same concern about their weight and body type, or have a disproportionately negative view of their body. (8)

Feelings of guilt and shame

Many people with ABN associate their binge eating episodes and the loss of control they experience with feelings of guilt and shame. (9) This can lead to:

  • Eating in secret
  • Lying about eating habits
  • Hoarding or hiding food
  • Feeling the need to purge

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When to get help for atypical bulimia nervosa

People with atypical bulimia nervosa face a variety of physical and psychological challenges. 

ABN often co-occurs with other mental health struggles. For example, people with bulimia or atypical bulimia nervosa have an increased risk of suicide. (10) 

Therefore, it’s important that someone potentially struggling with ABN gets help as soon as possible, before it severely impacts their physical and mental health. 

Even if there isn’t a preoccupation with weight or frequent binging episodes, anyone experiencing ABN symptoms may benefit from seeing a doctor who is familiar with eating disorders. There are many harmful effects of weight stigma in the healthcare profession. Fatphobia plays a huge role in why some people delay getting treatment, or avoid the doctor’s office all together. It is important to find a practitioner who has experience with eating disorders, as health care providers who do not can do more harm than good.

It can be hard to talk to anyone about your or your loved one’s disordered eating. But the right help and the right treatment can help address disordered eating habits and the associated physical effects of ABN, understand the reasons behind them, and help improve your overall well-being.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Ekern, B., (2016, February 16). Atypical Bulimia Nervosa: Signs and Symptoms. Eating Disorder Hope. 
  2. 10 Symptoms of Bulimia (2019, December 20). Facty.
  3. Harwood, M.P. and Newton, J.T. (1995), Dental aspects of bulimia nervosa: Implications for the health care team. Eur. Eat. Disorders Rev., 3: 93-102
  4. Pietrangelo, A. (2019, March 15). The Effects of Bulimia on your Body. Healthline. 
  5. Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol. 2005;6(3):165-73. 
  6. Kress, I. U., Paslakis, G., & Erim, Y. (2018). Differential Diagnoses of Food-Related Gastrointestinal Symptoms in Patients with Anorexia Nervosa and Bulimia Nervosa: A Review of Literature. Zeitschrift Für Psychosomatische Medizin Und Psychotherapie, 64(1), 4–15.
  7. Irritable Bowel Syndrome & Eating Disorders: Is There a Connection? (2019, July 30) WeightMatters. 
  8. Kirch W. (2008) Atypical Bulimia Nervosa. Encyclopedia of Public Health. Springer, Dordrecht.
  9. MediLexicon International. (n.d.). Physical and Emotional Side Effects of Bulimia on the Body. Medical News Today. 
  10. Udo, T., Bitley, S., & Grilo, C. M. (2019). Suicide Attempts in U.S. Adults with Lifetime DSM-5 Eating Disorders.BMC Medicine, 17(120).

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