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What are the signs and symptoms of bulimia nervosa?
"I felt shame and guilt, but I was fortunate that I lived alone at the time. If I was with people, I did everything I could to make it look like going to the bathroom was normal."

Signs and symptoms are a blend of mental, behavioral, and physical signs and symptoms. Some may be obvious only to a medical professional; others may be more easily noticed by friends and family. See the checklist for the most common signs and symptoms. Other less common symptoms may be present as well.

Binge eating and purging may seem like obvious signs that are hard to miss. But, these behaviors can be, and often are, well masked by a person with bulimia nervosa. People with bulimia nervosa may hide the behavior because they feel shame and guilt about it. The disorder may progress for some time before anyone else notices because the weight or outward physical appearance of people with bulimia nervosa may not change in the same way that appearance changes with an eating disorder like anorexia nervosa. Even an individual with a severe case of bulimia nervosa can appear to be of normal weight, or even be overweight. That is why weight is not used as a criterion in the DSM-IV for diagnosing bulimia nervosa.

Signs a healthcare professional may be most likely to notice

Certain healthcare professionals are in a position to observe the first clinical signs of the disorder. Dentists, in particular, may be the first to see signs because tooth, gum, and mouth problems are a common result of frequent purging by vomiting. Stomach acid, vitamin deficiency, and trauma from vomiting can decalcify teeth, erode enamel, cause cavities, and dry out and crack the skin of lips. Dentists may also notice swollen salivary glands in the mouth, a common side effect of frequent vomiting.

Other signs that a dentist or medical doctor may notice include "Russell's sign," named after the researcher who first identified bulimia nervosa. This is a sign in which the backs of the person's finger joints are particularly callused or discolored from using fingers to gag and induce vomiting. Nonprofessionals may notice this, but be unaware that it is a sign of bulimia nervosa. If the disorder is suspected, examination by a doctor using an endoscope to see into the lowest part of the esophagus may reveal slit-like tears from vomiting. Blood tests may also reveal electrolyte imbalances. More specific chemical imbalances that suggest bulimia nervosa are also listed.

Signs and symptoms that family and friends may be most likely to notice

People with bulimia nervosa may behave strangely around food. They might skip meals, rapidly change food likes and dislikes, avoid social outings that involve consuming food in front of others, or make excuses not to eat. People with bulimia nervosa may drink lots of water and diet soda or cut food into small bites and chew each bite excessively. Doing these things allegedly makes vomiting easier. They may also be excessively impulsive, depressed, or socially isolate themselves by choice from peers, friends, and family.

Purging behavior often is not obvious because the affected person may strive to hide it. Even roommates or spouses of people with bulimia nervosa can be totally unaware of purging behaviors for years because the affected person is extremely effective at hiding the behavior. For example, a person with bulimia nervosa may run water while in the bathroom to obscure the sound of vomiting. An affected person may use mouthwash, gum, and mints frequently, or excuse herself or himself from meals.

The non-purging behavior of excessive exercise can be noticed by friends and family, but if the individual is a bulimic athlete, it is very difficult to draw the line between training and excess exercise. Fasting may be less obvious if the person makes reasonable excuses for not eating in certain situations.

Signs and Symptoms Health Professionals May Observe

  • Dental sensitivity
  • Dry mouth
  • Enamel erosion
  • Irregularly-shaped biting edges of teeth
  • Bleeding or irritated gums
  • Tooth decalcification
  • Increase in number of cavities
  • Dry, red, cracked lips, especially at corners
  • Swollen cheeks and jaw
  • Bloodshot eyes
  • Swollen salivary glands (sialadenosis)
  • Callused and/or discolored skin on the finger joints (Russell's sign)
  • Abnormal blood test results that show metabolic acidosis (blood too acidic); metabolic alkalosis (blood too alkaline); hypochloremia (chloride too low); hypokalemia (potassium too low); hyperamylasemia (amylase too high); or hypercholesterolemia (cholesterol too high)

Signs and Symptoms that Family and Friends May Observe

  • Appears uncomfortable eating around others
  • Buys large amounts of food that disappear with no explanation
  • Skips meals
  • Takes small food portions at regular meals
  • Mixes strange foods
  • Insists on isolating foods from each other on a plate
  • Sudden changes in food likes and dislikes
  • Stops eating a particular food or food group
  • Eats only a particular food or food group (e.g., condiments)
  • Offers excuses for not eating at regular meals with family/friends
  • Declines social engagements that involve food
  • Isolates self from interactions with family and friends
  • Engages in excessive exercise regimens
  • Hides body with larger, baggy clothes
  • Has distorted perception about body size and shape
  • Shows signs of depression (lack of concentration, mood swings, isolation)
  • Cuts food into small pieces
  • Chews each bite excessively
  • Drinks excessive amounts of water or soda
  • Excuses self from meal before anyone else
  • Keeps family out of his/her room
  • Excessive requirements for privacy in bedroom and bathroom
  • Avoids looking at self in mirrors

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Bulimia nervosa is an eating disorder in which a person engages in binge eating (eating a lot of food in a short time) followed by some type of behavior to prevent weight gain from the food that was eaten. This behavior can take two forms: self-induced vomiting, misuse of enemas, laxatives, diet pills (called purging) and excessive exercise, fasting, or diabetic omission of insulin (called non-purging). Some people with bulimia nervosa may also starve themselves for periods of time before binge eating again. Bulimia nervosa has important mental, emotional, and physical aspects that require consideration during treatment.

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