Bulimia nervosa is an eating disorder characterized by frequent uncontrolled binge eating followed by compensatory behaviors to prevent weight gain, such as vomiting, use of laxatives or diuretics, fasting, and/or excessive exercise. Unlike anorexia nervosa, which results in very low body weight, those with bulimia nervosa may have healthy weight or be overweight. However, a preoccupation with body image can contribute to unhealthy eating habits and behaviors.
The stigma associated with binging and purging often results in secrecy that prevents people from obtaining a diagnosis and getting the care they need.
How common is bulimia nervosa?
Eating disorders can affect anyone, but appear to be more common among female adolescents, young women, and lesbian, gay, bisexual, and transgender individuals.
The National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III) estimated a lifetime prevalence of bulimia nervosa in the United States using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Based on this survey of 36,306 adults, the lifetime prevalence of bulimia nervosa was 0.28 percent, and the prevalence was higher for women and adults over the age of 45. This translates to about two percent of women and less than one percent of men during their lifetimes, though the epidemiological landscape may be changing as surveys encompass broader segments of the population.
Is stigma a barrier to diagnosis?
To establish a diagnosis of bulimia nervosa, the DSM-5 criteria require recurrent episodes of binge eating and compensatory behaviors that occur at least once weekly for at least three months. In addition to these, a person’s thoughts about their weight and body image have excessive influence on their self-image. When combined with weight bias (i.e., negative assumptions, beliefs, and judgments about a person based on their weight), it can be distressing to disclose their binging and purging behaviors.
Eating disorders are acknowledged to be stigmatized mental health disorders. Research has found that others tend to view people with eating disorders as responsible for their situation. Clinicians, too, have been found to respond negatively to people with eating disorders, even expressing personal frustration and anger. The psychological, social, physical, and behavioral outcomes of such stigma can contribute to loss of self-esteem, social withdrawal, more severe symptoms of eating disorders, depressive symptoms, poor physical health, and a reluctance to seek treatment.
Steps toward the diagnosis.
Negative beliefs about eating disorders and the reticence of patients to share stigmatizing thoughts and behaviors can make it challenging for clinicians to elicit information from their patients about body image dissatisfaction, disordered eating and/or exercise patterns, and other unhealthy weight control behaviors. Approaching such discussions with empathy and respect may encourage patients to share aspects of their thinking and habits that they may otherwise try to keep to themselves.
For instance, asking about the type, frequency, and intensity of a person’s diet (including calorie counting and restriction of macronutrients) and exercise patterns without judgment may open communication channels. Simple screening questions at an opportune time during the clinical encounter may be helpful (a recent assessment of screening questions can be found here). More than two affirmative answers to the following (or similar) questions could indicate an eating disorder:
- Do you ever worry that you may have lost control over how much you eat?
- Have you recently lost more than ten pounds over a three-month period?
- Do you believe yourself to be fat?
- Would you say that food dominates your life?
- Do you make yourself sick because you feel uncomfortably full?
Though such questions are not meant to be diagnostic in themselves, they can help to inform and contextualize a patient’s medical history and state of mental and physical health. The 2023 American Psychiatric Association recommends screening for the presence of eating disorders as part of an initial psychiatric evaluation.
Physical signs of bulimia nervosa may be more obvious. Recurrent vomiting can cause poor oral health, including tooth erosion, gum disease, dental caries, palatal scratches, salivary gland enlargement, and other signs. Abrasions or calluses on the backs of the hands (known as Russell sign) can occur with self-induced vomiting. Frequent laxative use can cause peripheral edema, hemorrhoids, or rectal prolapse. Metabolic and gastrointestinal complications can often be detected later in the disease course.
Eating disorders involve interactions between genetic, environmental, and psychosocial factors. Once diagnosis is confirmed, most patients can be treated in an outpatient setting with individual or family psychotherapy, nutrition counseling and support, and treatment of sequalae and overall health.
For handouts and information to share with your patients, see DynaMedex Patient Information for Bulima Nervosa.