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Signs and symptoms of bulimia nervosa

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Bulimia nervosa (BN) is a serious illness that can be life threatening when left untreated. Learning the signs and symptoms of bulimia nervosa may help you identify this condition in yourself or a loved one, which is the first step in getting help.

Last updated on 
August 24, 2023
In this article

Signs of bulimia nervosa

“Signs” and “symptoms” are often thought of as synonyms and may appear together when describing the effects of an illness. But the two actually have different medical meanings, and each is an important part of understanding and identifying an ongoing issue.

When it comes to illnesses, “signs” are aspects of the illness that are outwardly measurable. This means a friend, family member or doctor can independently observe or track the progression of an illness. Further, signs (and symptoms) can manifest either physically or through a person’s emotions and behavior. 

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Physical signs of bulimia nervosa

As with most eating disorders, bulimia has a number of physical signs. (1,2,3) Many signs of bulimia are outwardly detectable.

Injured esophagus

An injured esophagus may not appear right away, but it’s one telltale sign of bulimia, because of the purging aspect of the disorder. 

The passage of vomit through the esophagus exposes it to caustic stomach acid found This can seriously damage the sensitive tissue lining the throat. The methods used to induce vomit—e.g., sticking fingers or objects in the throat—can also lead to injury.

An injured esophagus can start as a perpetually sore throat or difficulty swallowing, then  develop into a more serious issue, such as esophageal tearing, scarring, or strictures.

Tooth damage or sensitivity

The teeth and mouth in general are also at-risk areas for people struggling with bulimia. Damage to the teeth is due to stomach acid that regularly gets regurgitated during purging episodes.

Prolonged exposure to such acids could weaken tooth enamel or eventually wear it away all together, resulting in tooth sensitivity and cavities. Other areas of the mouth, including taste buds, tongue, and roof of the mouth, can also be damaged by stomach acid.

Bruised/injured knuckles

Most forms of bulimia involve episodes of binging and purging, where a person forces themselves to vomit after eating. To induce that reaction, many people stick their fingers or their hands down their throat.

This action can lead to another common sign of bulimia: bruised, injured, red and raw, or callused knuckles. Formally called Russell’s sign, the injury is typically caused by a person accidentally biting down on their hand or finger while inducing the gag reflex.  (5)

Changes in bone density/muscle mass

More physiological effects of bulimia are tied to the irregular distribution or absorption of nutrients in the body. This can result in signs such as the loss of bone density or muscle mass.

People struggling with bulimia are historically at-risk for osteoporosis, due to a lack of minerals that help build strong bones and hormonal imbalances that may be triggered by BN. (6)

Muscle mass can also be lost as the disorder goes on, despite potentially excessive exercise routines, because of malnutrition resulting from bulimia.

Thin/brittle hair and nails

Dietary restrictions and malnutrition have impacts on nearly every part of the body, including hair and nails. The condition of these two features is often seen as a marker of a person’s health, as  balanced nutrition is essential for growing healthy hair and nails. (7) Brittle nails with white spots can develop as signs of malnutrition.

Hormonal imbalance, including the increased level of the stress hormone cortisol typically found in people struggling with bulimia, can  cause hair to thin or fall out. (6) 

Irregular or absent menstrual periods

Irregular or missed periods, also called amenorrhea, is another common sign of bulimia.

The cause is typically twofold: The disorder can severely restrict the calories and minerals—especially iron—needed to keep the body and blood cells functioning normally.  Bulimia also triggers hormonal imbalances, suppressing the necessary mechanisms needed to produce enough estrogen. (8)

Heart problems

The cardiovascular complications derived from bulimia can be tied to a number of factors, but the most prominent seems to be the electrolyte imbalance the disorder causes. (9)

Electrolytes play a huge role in maintaining a regular heartbeat.  This can lead to a number of issues when they’re out of balance, including arrhythmia or low blood pressure. People struggling with bulimia are also at an increased risk of cardiovascular disease, thanks to additional risk factors, like anxiety, that often accompany the disorder. (9)


Emotional and behavioral signs of bulimia nervosa

Bulimia takes a huge toll on the body. But the disorder originates in the mind. When dealing with the illness, someone struggling with bulimia may display a number of emotional or behavioral signs. (1,2,3)

“Disappearing” after meals

Disappearing to purge a meal just eaten is one of the most prominent outward signs of bulimia.

While not all forms of bulimia involve this type of behavior, it’s an extremely common expression of the illness. 

Excessive exercise routines

Just as not all types of bulimia include purging, not all types necessarily involve an excessive exercise routine. But both behaviors are strong signs of the disorder.

Excessive exercise looks different than typical  forms of exercise.. Someone undergoing this behavior might seem obsessed or preoccupied with working out. They may regularly work themselves much harder and longer than necessary and work out regardless of fatigue, injury, illness or other factors that might otherwise dissuade someone. Often, the routine is seen as a way to compensate for any calories that were consumed.

Unnecessary use of diuretics

Many people struggling with bulimia also turn to diuretics to help them purge. This could include everything from laxatives to enemas to types of drinks meant to induce a bowel movement.

While it may make medical sense to use these substances from time to time, someone struggling with bulimia will tend to use them regularly, whether or not they’re actually needed.

Hiding foods or signs of eating

The equal-and-opposite side of purging is the binging that’s involved in bulimia. However, many people struggling with the disorder may be embarrassed or ashamed of this behavior and try to hide it or any signs that they may be eating more than they let on.

This sign can look like everything from food wrappers stuffed under the bed, snacks stashed in secret hiding spots, or a person who simply declines to eat in front of other people.

Wearing baggy clothes

Like many eating disorders, bulimia is often accompanied by a sense of shame or a desire for secrecy around the illness. And one common way many people struggling with the disorder try to hide it from others is by hiding the true shape of their body.

As such, many people with bulimia may dress in oversized or baggy clothes. This could also be related to the person’s general discomfort with the size and shape of their body, which is another typical psychological symptom of the disorder.

Health Complications of Bulimia

Symptoms of bulimia nervosa

Symptoms of an illness are effects that only the person experiences and may be hard for others to see.

Bulimia affects the physical, psychological, and social aspects of a person’s life and may present with the following symptoms. 

Physical symptoms of bulimia nervosa

Due to the harmful impact bulimia can have on the physical body, the disorder can be accompanied by a number of physical symptoms only the patient can experience. (1,2,3)

Binge eating episodes

One of the most common symptoms of bulimia involves periods of eating an excessive amount of food. Binging episodes can be triggered by feelings of stress, anxiety, or simple hunger following periods of severely restricted calorie intake. (10)

While binging, the person will consume a very large amount of food and may even experience the feeling of losing control over how much they consume.

Severe diet swings

It’s also possible for people with bulimia to compensate for binge eating by severely restricting their diet. Aside from physical purging, this can be accomplished by periods of fasting, severe calorie restriction, or crash dieting. (10)

From the outside, this behavior may be undetectable at all or appear as someone who refuses to eat with others or is constantly on a diet.

Constipation/GI discomfort

The act of regularly regurgitating food can also cause significant gastrointestinal discomfort, because of the physical mechanics used to bring food back up and the effect of stomach acid on the esophagus and other areas.

Acid reflux, constipation, bloating, irritable bowel syndrome, abdominal distension, and gastric perforation are all potential side effects of this behavior. (11)

Impaired mental sharpness

People struggling with bulimia can tend to “not feel on top of their game,” thanks to the constant changes going on in their bodies. The electrolyte imbalance typical of bulimia is perhaps the most prominent cause of this problem and causes a number of physical symptoms, including feelings of confusion, lethargy, or dizziness. (12)

Emotional and behavioral symptoms of bulimia nervosa

Finally, bulimia can present as a number of emotional or behavioral symptoms. (1,2,3) These effects of the disorder may be some of the most insidious, as they can potentially be both the hardest to detect and the most difficult to change.

Preoccupation with body size and weight

This emotional symptom is, in many ways, the driving force behind bulimia. The person’s preoccupation with the size, shape, and weight of their body is one of the main factors compelling them to compensate for their binge eating behavior by purging.

Anxiety and/or depression

People struggling with bulimia can also struggle with depression and anxiety, as these disorders often co-occur with BN. Anxiety can drive someone to binge eat. Fear, guilt, or shame may also cause someone to purge. And depression may make it more difficult for someone to break out of these destructive cycles. (15)

Mood swings

Both the psychological aspects of the disorder, including depression and anxiety, or the more physical signs of bulimia, including hormone imbalances, can result in mood swings. Symptoms may include hair-trigger tempers, hypersensitivity, irritability, avoidant behavior, or other types of unusual or unstable emotional reactions.

Signs and symptoms of other eating disorders

When to get help for bulimia nervosa

Bulimia nervosa is a serious medical issue that can be potentially fatal if left unchecked.

Fortunately, the illness is entirely treatable, with 74% of patients able to make a full recovery after receiving proper help. (13) If you think you or someone you love may be struggling with any of the signs and symptoms of bulimia, it’s important to seek help. 

Here are a few things to consider when seeking out professionals who can help:

It can be hard to identify providers who are trained and knowledgeable about disordered eating. Medical providers are not always familiar with the nuances of eating disorders and the multidisciplinary team approach that is often most helpful to treat eating disorders effectively.

In fact, they may not be aware of all the risks involved and potential harm providers unknowingly and unintentionally inflict by being uninformed. Many health care providers do not fully understand how a preoccupation with body mass index (BMI), internalized weight stigma or fat phobia, and diet culture can have a negative impact on people who are struggling with eating and body image challenges--and may even make eating disorders worse.

A comprehensive treatment approach may entail a team of medical professionals, dietitians, counselors, therapists, and other practitioners to help patients in their healing journey. You can start with your primary care provider who can then refer you to some appropriate resources.

A more intensive therapeutic approach may be needed, as bulimia can be very serious and life threatening.  Here are a few suggestions to  think about before considering inpatient treatment or a more intensive care routine for bulimia, including: (14)

  • The level of care available
  • Financial aspects of treatment
  • Whether at-home attempts to stop bulimic behaviors have been tried
  • Whether at-home attempts to stop bulimic behaviors have been successful
  • Whether dangerous secondary symptoms, such as self-harming, have developed
  • Whether psychiatric stabilization is necessary

If you or someone you love is looking for help with their eating disorder, Within Health offers a virtual care program for people with bulimia nervosa. Call our team to learn more about our compassionate client care.

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.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.


  1. Mayo Clinic. (2018, May). Bulimia Nervosa.
  2. Eating Recovery Center. (2021). Signs and Symptoms of Bulimia Nervosa.
  3. Within Health. (2021). Bulimia Nervosa.
  4. Merck Manual. (2021). Overview of Esophageal Injuries.
  5. International Journal of Eating Disorders. (2001, September). The Interrater Reliability of Physical Signs in Patients with Eating Disorders.
  6. European Journal of Endocrinology. (2006, August). Bone Mineral Density in Bulimic Women – Influence of Endocrine Factors and Previous Anorexia.
  7. Eating Disorders and the Skin. (2012, June). Eating Disorders and the Nails. 
  8. Eating Disorders. (2010, May). Can an Eating Disorder Affect Your Fertility?.
  9. JAMA Psychiatry. (2019, October). Association of Bulimia Nervosa With Long-term Risk of Cardiovascular Disease and Mortality Among Women. 
  10. National Institute of Mental Health. (2021). Eating Disorders: About More Than Food.
  11. National Center for Biotechnology Information. (2015, October). Gastrointestinal symptoms and disorders in patients with eating disorders
  12. University of Pittsburgh Medical Center. (2021). Electrolyte Deficiency Disorders. 
  13. Biological Psychiatry. (2007, February). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. 
  14. Clementine. (2018, June). Bulimia Nervosa: When Is It Time to Seek Treatment?. 
  15. The Journal of Abnormal Psychiatry. (2017). The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis.


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