Bulimia Nervosa

Bulimia gets a lot of negative attention in our society.
P!nk pretended to have Bulimia in her ‘Stupid girls’ film clip.
School girls joke about sticking their fingers down their throat to get boy’s attention.
Bulimia is not a joke, nor is it a ‘stupid girl’ diet. It is a serious mental illness that requires psychological and often medical intervention, and people living with this illness deserve to be acknowledged and respected.

The DSM-V is the diagnostic manual created by the American Psychological Association (APA), and in it contains the diagnostic criteria for each of the Eating and Feeding Disorders. As per the DSM-V, for an individual to be diagnosed with Bulimia Nervosa, they must display;

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  2. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
  3. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
  4. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
  5. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
  6. Self-evaluation is unduly influenced by body shape and weight.
  7. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Once the diagnosis is made, it’s severity is then classified through measurement of frequency of disordered behaviours.

  • Mild: An average of 1–3 episodes of inappropriate compensatory behaviours per week.
  • Moderate: An average of 4–7 episodes of inappropriate compensatory behaviours per week.
  • Severe: An average of 8–13 episodes of inappropriate compensatory behaviours per week.
  • Extreme: An average of 14 or more episodes of inappropriate compensatory behaviours per week.



Although not specified in the DSM-V, Diabulimia is a serious Eating Disorder with severe medical complications. It is a form of Bulimia seen in people with type 1 diabetes, Diabulimia is the restriction of medicated insulin in order to lose weight. As Insulin is thought of as a ‘fat storage hormone’, people who miss doses of their insulin can theoretically lose weight. As you may imagine, there are significant complications that arise from this, as the body is put into a state of hyperglycaemia. These include

  • Exhaustion
  • Excessive thirst
  • Inability to think clearly
  • Severe dehydration
  • Muscle loss
  • Diabetic Ketoacidosis (unsafe levels of ketones in the blood)
  • High Cholesterol
  • Bacterial skin infections
  • Yeast infections
  • Menstrual disruption
  • Staph infections
  • Retinopathy
  • Neuropathy
  • Peripheral Arterial Disease
  • Atherosclerosis (a fattening of the arterial walls)
  • Liver disease
  • Stroke
  • Coma
  • Death

It is estimated that almost 1/3 of young women with type 1 diabetes will demonstrate behaviours of Diabulimia at some stage through their lives. That’s too many.

If you or someone you know is living with Diabulimia and you’re looking for more information, the Diabulimia Helpline (based in the USA) is an excellent resource for support and further education. You can find them at:


What does Bulimia Nervosa look like?

Identifying Bulimia can be tricky, as all Eating Disorders tend to be secretive and hidden illnesses. However, there are tell tale signs and symptoms that you might start to notice in your loved ones.

  • Unexplained weight loss (please note that not everyone with Bulimia will experience weight loss with their illness)
  • Recurrent conversation about body image or weight loss
  • Eating in private, or dismissing self early from a meal to be alone
  • Depression, anxiety and/or mood swings
  • Exhaustion and/or not sleeping well
  • Withdrawal from social, recreational and occupational activities and responsibilities
  • Scarring or markings on knuckles (due to frequent purging)
  • Swollen face
  • Stashing of large amounts of food and/or vomit/regurgitated food in secret
  • Stashing of diet pills, laxatives, or diuretics
  • Dismissive when asked about eating habits or weight loss
  • Extreme sensitivity to comments about appearance

In regards to Diabulimia, you may also notice;

  • Persistent thirst/frequent urination
  • Secrecy about blood sugars, shots and or eating.
  • Increased appetite especially in sugary foods.
  • Cancelled doctor appointments


What causes Bulimia Nervosa?

Like all Eating Disorders, Bulimia is caused by a combination of things. There may never be a clear-cut answer as to what has caused a particular person’s illness, but there tends to be the presence of issues in at least one of three areas;

  • Biological (genetic susceptibility)
  • Environmental (societal pressures/thin ideal, toxic family, lack of supports, history of bullying, neglect or abuse)
  • Personality (perfectionism, impulsivity/emotional dysregulation, neuroticism


How does Bulimia Nervosa affect the body?

The major cause of resultant medical conditions that come with Bulimia Nervosa are results of malnutrition and intense stress placed on the body during bingeing and purging. That may look like;

  • Weight loss
  • Fatigue
  • Dehydration
  • Headaches
  • Fainting
  • Facial swelling (oedema)
  • Loss of tooth enamel (resulting from frequent purging)
  • Discoloured knuckles and scarring (resulting from frequent purging)
  • Damage to oesophagus; tearing, bleeding, bursting (critical result and requires immediate medical intervention)
  • Acid reflux
  • Swollen salivary glands
  • Mouth ulcers and sores around mouth
  • Tooth and gum disease
  • Stomach tearing and ulcers
  • Constipation
  • Bloating
  • Anaemia (low levels of iron in the blood)
  • Dangerous electrolyte Imbalance
  • Lowered immunity
  • Dizziness and low blood pressure
  • Hair loss
  • Lowered libido
  • Infertility due to loss of period in females or low sperm count in males
  • Osteoporosis (loss of bone density) which puts a person at higher risk of fractures
  • Loss of muscle tone
  • Low heart rate
  • Weakened heart/heart failure
  • Cardiac arrest
  • Kidney failure
  • Seizures
  • Death

And that’s just the physical effects of Bulimia. There are multiple cognitive and behavioural implications that are very often overlooked;

  • Obsession with calories, food, preparation of food
  • Distorted image of self and body
  • Low self esteem
  • Rigidity around meal times
  • Ritualistic behaviours around food and food preparation
  • Mood swings
  • Persistent low moods
  • Overwhelming anxiety
  • Irritability
  • Feelings of being out of control
  • Rigid thinking
  • Strong urges to engage in disordered behaviours despite exhaustion (i.e. Excessive exercise)
  • Social isolation
  • Constant feelings of guilt and shame
  • Avoidance of all activities involving food or body (e.g. going to the beach, attending family dinner, showering and seeing body in mirror)
  • Obsessive body checking behaviours
  • Dissatisfaction with body that causes significant distress
  • Excessive spending on food for binge-eating or other means of losing weight (gym memberships, diet pills, laxatives, diuretics, etc).
  • Recurrent suicidal thoughts
  • Suicide attempts
  • Self harm


How is Bulimia Nervosa treated?

Treatment for all Eating Disorders require intervention in the following domains;

  • Medical/Physiological: monitoring of weights and blood levels, management of medical complications (e.g. Potassium or other electrolyte infusions), weight restoration in or out of hospital, medication.
  • Psychological: psychotherapy (cognitive behavioural therapy and dialectical behavioural therapy most common), exposure therapy with ‘fear foods’.
  • Nutrition: creating and maintaining a meal plan (as per dietitian).
  • Environmental: addressing possible issues within the family/home environment, support from peers, networking with other people with an Eating Disorder to share experiences.

These areas can be addressed both within and outside the hospital system, however it is recommended that a person has a strong, supportive team of professionals around them at all times to address their needs in recovery. A team is usually made up of a psychiatrist, general practitioner, psychologist, counsellor, dietitian, and in some cases a social worker, occupational therapist or physiotherapist. Models of care occur within inpatient settings (public or private hospital, in either dedicated Eating Disorder ward or general psychiatric ward), partial inpatient settings (day programs within the community) and outpatient settings (attending private sessions with health professional).

It is common for people with an Eating Disorder, to also be experiencing one or more other mental illnesses. It is therefore important for these to be managed with medication and/or psychotherapy. A person may also have a lot of underlying maladaptive coping mechanisms, and should be educated and encouraged to seek out healthier alternatives to use when experiencing distress. For example, instead of using a binge/purge event to cope with overwhelming feelings of rejection from a family member, reach out to a trusted friend, or journal thoughts and feelings that arise. This process is incredibly difficult for the person to do, as turning to their Eating Disorder for comfort is both a habit and a safety net. Taking that away, can cause further distress on top of the stressful situation that initially triggered them.

A supportive and understanding social network is also important in recovery, as our friends and family are the ones who are with us 24/7. Therapists and doctors encourage strong family involvement, especially when a person is under the age of 18. They address concerns within the family dynamic to ensure when a person is discharged from a service, they are going into a safe environment in which they will be supported to continue recovery.