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Section 17
Bulimia Nervosa, Part III: Symptoms and Medical Consequences

Question 17 | Test | Table of Contents

How Serious Is Bulimia Nervosa Without Serious Weight Loss (Anorexia).
Chances for Recovery
Some studies have suggested that between 60% and 80% of patients are in remission within three months of treatment. However, relapse is common and up to half of women with bulimia continue to battle disordered eating habits for years, with bulimia itself persisting in 10% to 25% of patients.

Medical Consequences
In general, there are few major health problems for bulimic people who maintain normal weight and do not go on to become anorexic. For example, one study comparing adolescents with anorexia and bulimia reported abnormal heart rhythms in patients with anorexia but not in those with bulimia. It should be noted, however, that in one study of bulimic patients undergoing therapy, after six years the mortality rate was 1%. Those who have both bulimia and anorexia, however, are in great danger. [See How Serious Is Anorexia Nervosa? below.]

And, the disorder, even without anorexia, is not without health problems and serious risks. The following are medical problems associated with bulimia:

• Teeth erosion, cavities, and gum problems.
• Water retention, swelling, and abdominal bloating.
• Occasionally, fluid loss with low potassium levels. This occurs from excessive vomiting or laxative use. In severe cases it can cause extreme weakness, near paralysis, or lethal heart rhythms.
• Acute stomach distress.
• Problems in swallowing. This is an area of possible concern because of repetitive assaults on the esophagus (the food pipe) from forced vomiting. It is not clear, however, if this problem is common.
• Rupture of the esophagus, or food pipe. (Cases have been reported with forced vomiting but are not common.)
• Weakened rectal walls. In rare cases, walls may weaken to the extent that they protrude through the anus. This is a serious condition that requires surgery.
• Most pregnant women with a history of eating disorder have healthy pregnancies, although they face higher risks for a number of complications, including cesarean sections, postpartum depression, miscarriages, and complicated deliveries. Their babies may also have a higher risk for low birth weight, pre-maturity, and malformation.
• Irregular periods. (It should be noted that menstrual irregularities in patients with bulimia do not have the serious effects, particularly bone loss, as they do in patients with anorexia.)

Self-Destructive Behavior
A number of self-destructive behaviors occur with bulimia:

• Smoking. Many teenage girls with eating disorders smoke because it is thought to help prevent weight gain.
• Impulsive Behaviors. Women with bulimia are at higher-than-average risk for dangerous impulsive behaviors, such as sexual promiscuity, self-cutting, and kleptomania. Some studies have reported such behaviors in half of those with bulimia.
• Alcohol and Substance Abuse. An estimated 30% to 70% of patients with bulimia abuse alcohol, drugs or both. This rate is higher than for the general population and in people with anorexia. It should be noted, however, that this higher rate of substance abuse may be a distortion, because studies are conducted only on diagnosed patients. Bulimia tends not to get diagnosed. And, reports of bulimia in the community (where the incidence of the eating disorder is higher than statistics suggest) indicate that substance abuse is actually lower than in people with anorexia.

Abuse of Over-the-Counter Medications
Women with bulimia frequently abuse over-the-counter medications, such as laxatives, appetite suppressants, diuretics, and chugs (e.g., ipecac) that induce vomiting. None of these drugs is without risk. For example, ipecac poisonings have been reported, and some people become dependent on laxatives for normal bowel functioning. Diet pills, even herbal and over-the-counter medications, can be hazardous, particularly if they are abused.

Symptoms Specific to Bulimia without Anorexia
People with bulimia nearly always practice it in secret, and, although they maybe underweight, they are not always anorexic.

Symptoms or signs of bulimia, then, may be very subtle and go unnoticed. They may include the following:

• Evidence, such as discarded packaging, of laxatives, diet pills, emetics (drugs that induce vomiting), or diuretics (medications that reduce fluids).
• Regularly going to the bathroom right after meals.
• Suddenly eating large amounts of food or buying large quantities that disappear right away.
• Compulsive exercising.
• Broken blood vessels in the eyes (from the strain of vomiting).
• Swollen salivary glands. These occur within days of vomiting in about 8% of people with bulimia. They often give a pouch-like appearance to areas below the comers of the mouth.
• Dry mouth
• Teeth develop cavities, diseased gums, and irreversible enamel erosion from excessive acid. (Gargling with baking soda after purging rather than using toothpaste may help neutralize the acid.)
• Rashes and pimples
• Small cuts and calluses across the tops of finger joints. (These cuts can occur from repeated self-induced vomiting, in which a person thrusts the hand down the throat past the front teeth.)
- Eating Disorders; Eating Disorders: Anorexia and Bulimia; (A.D.A.M.); 2002.

Personal Reflection Exercise #3
The preceding section contained information about the symptoms and medical consequences of bulimia.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Using Network Analysis to Explore
the Association between Eating Disorders Symptoms
and Aggressiveness in Bulimia Nervosa

Cascino, G., Marciello, F., D'Agostino, G., Toricco, R., Barone, E., & Monteleone, A. M. (2022). Using network analysis to explore the association between eating disorders symptoms and aggressiveness in Bulimia nervosa. Frontiers in psychiatry, 13, 907620.

Peer-Reviewed Journal Article References:
Farstad, S. M., & von Ranson, K. M. (2021). Binge eating and problem gambling are prospectively associated with common and distinct deficits in emotion regulation among community women. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 53(1), 36–47.

Radin, R. M., Epel, E. S., Daubenmier, J., Moran, P., Schleicher, S., Kristeller, J., Hecht, F. M., & Mason, A. E. (2020). Do stress eating or compulsive eating influence metabolic health in a mindfulness-based weight loss intervention? Health Psychology, 39(2), 147–158.

Schaefer, L. M., Smith, K. E., Anderson, L. M., Cao, L., Crosby, R. D., Engel, S. G., Crow, S. J., Peterson, C. B., & Wonderlich, S. A. (2020). The role of affect in the maintenance of binge-eating disorder: Evidence from an ecological momentary assessment study. Journal of Abnormal Psychology, 129(4), 387–396.

QUESTION 17
What are three impulsive behaviors for which women with bulimia are at a higher-than-average risk for? To select and enter your answer go to Test.

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