Physical 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 slightly different medical meanings, and each is an important part of understanding and identifying an ongoing issue.
"Signs” are aspects of the illness that are outwardly measurable. This means a friend, family member or doctor can independently observe or track these factors. And while most signs of BN or other eating disorders manifest physically, they can also appear through a person’s emotions and behavior.
Below are some common signs of bulimia nervosa.
Injured esophagus
An injured esophagus may not appear right away, but it can frequently occur with bulimia nervosa, particularly in those who use self-induced vomiting as a compensatory behavior.
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Repeatedly exposing esophageal tissue to caustic stomach acid can lead to irritation and other gastrointestinal issues, including acid reflux.
1 Sticking fingers in the throat also exposes it to potential injury.
In serious cases, the repeated vomiting can cause something called a Mallory Weiss tear, or a tear or split along the esophageal lining. These injuries usually heal on their own, despite being painful and causing potentially scary side-effects, such as
vomiting blood, dizziness, weakness, and heart palpitations in serious cases.
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Damage to the mouth, teeth and salivary glands
The
teeth and mouth are also at-risk areas for people struggling with bulimia nervosa. Damage to the teeth primarily occurs in people with purging type BN, due to stomach acid eroding away at tooth enamel. Prolonged exposure to such acids can also cause tooth sensitivity and cavities.
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The self-induced vomiting involved in bulimia nervosa can also lead to inflamed salivary glands, in a condition called parotid sialadenosis.
5 Sometimes referred to as "
bulimia cheeks," this leads to a puffed-up looking face.
Bruised/injured knuckles
In many cases, people with BN utilize self-induced vomiting as a compensatory measure to avoid gaining weight. To trigger that reaction, many people stick their fingers or their hands down their throat.
This action can lead to other common signs of bulimia: bruised, injured, red and raw, or callused knuckles.
1,2 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.
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.4
People struggling with bulimia may be at greater risk of developing osteoporosis, as they commonly have a lower bone mineral density.4 This can be the result of several issues related to disordered eating behaviors, including malnutrition and hormonal dysregulation.
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.6
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 also cause hair to thin or fall out.7
Irregular or absent menstrual periods
Irregular or missed periods, also called
amenorrhea, is another common sign of bulimia.
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The exact cause of the issue is still being studied, though it’s thought that the disruption of several hormones related to menstruation and fertility lead to both amenorrhea, or the absence of a menstrual period, or irregular menstrual cycles in women with BN.
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Heart problems
One of the most dangerous signs of bulimia nervosa are the
cardiovascular complications the eating disorder can lead to. These issues can be tied to a number of factors, but the most prominent seems to be the electrolyte imbalance the disorder causes.
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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.
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Emotional and behavioral signs of bulimia nervosa
Bulimia nervosa takes a huge toll on the body, but the disorder ultimately originates in the mind. As such, there are a number of emotional or behavioral signs of bulimia, which may be related to the mental health aspect of the condition.1,2
Strange behavior around mealtime
Since many people with BN use self-induced vomiting to prevent weight gain, they may commonly disappear immediately after a meal in order to purge. But people struggling with this condition also often struggle with mealtimes in general, and may skip meals or avoid situations that involve preparing food or eating with others.
Misuse of laxatives
Another common compensatory behavior in purging type bulimia nervosa is the misuse of laxatives, enemas, and diuretics. The prevailing thought is that these medications can help someone rid their body of food and calories after a binging session, though the substances
don't actually contribute to weight loss or maintenance in that way.
Excessive exercise routines
Purging type bulimia, which involves physically expelling food from the body, is the more well-known type of BN, but the disorder can also manifest through non-purging compensatory behaviors. One of the most common expressions of non-purging BN is the use of
excessive exercise to "make up for" binge eating episodes.
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.
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, late-night runs to the store to get snacks, or large amounts of food that go missing from the fridge or pantry.
Wearing baggy clothes
Like many eating disorders, bulimia nervosa 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, even though many people with BN present with "normal weight."
Dressing in oversized or baggy clothes is a common way to hide one's body. 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 nervosa
Physical bulimia nervosa symptoms
As opposed to signs of an illness, which can be outwardly observed or measured, symptoms describe the suite of issues that can only be felt by the person experiencing them. While these may be more difficult to track, they can often feel more intense or uncomfortable for the person with the illness or eating disorder.
There are also many common symptoms of bulimia.
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 these episodes are also marked by the loss of a sense of control over how much or what is consumed.
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
Emotional and behavioral bulimia nervosa symptoms
Unlike the signs of bulimia nervosa, the symptoms of bulimia nervosa are more likely to manifest in someone's behaviors and emotions than in a physical way. 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.1,2
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 that makes them hyper-fixate on food, whether in restricting it, binging on it, or making up for that binge with compensatory behavior.
Anxiety and/or depression
Mood disorders of all types
commonly co-occur with bulimia nervosa, though depression and anxiety disorders share a particularly strong connection with the condition. Mood disorders can pre-date BN and work in developing eating disorders, or they can develop as a symptom of the disordered eating and thinking involved in bulimia nervosa.
Anxiety can drive someone to binge eat. Fear, guilt, or shame may also cause someone to purge. And sadly, depression can make it more difficult for someone to break out of these destructive cycles.
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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 many patients able to make a full recovery after receiving proper help.
If you think you or someone you love may be struggling with any of the signs and symptoms of bulimia nervosa, it’s important to seek help as soon as possible.
How to find help for bulimia nervosa
There are a few things to keep in mind when seeking out professionals who can help with BN or other eating disorders, like anorexia nervosa (AN) and binge eating disorder (BED).
As eating disorders impact physical, mental, and emotional health, a comprehensive treatment approach is often the best way to address these diverse issues. Generally, this is performed by a multidisciplinary team of experts, including dietitians, therapists, psychiatrists, primary care physicians, and other practitioners.
When looking for this type of help, you can start by contacting your primary care provider or therapist. These experts can help you secure an eating disorder diagnosis—often the first step toward securing a spot in a treatment program—or guide you in the next best steps.
Remote treatment for bulimia nervosa
We understand the many facets of eating disorders like BN and offer a virtual care program to help cater to each patient's specific needs. Our multidisciplinary team will craft individual treatment plans for each patient, and sessions can all be completed at home, through our easy-to-use website and app.
Call our team to learn more about our compassionate client care.
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