Symptoms & Signs
The essential feature of bulimia nervosa is the episodic, uncontrolled gorging of large quantities of food in short periods of time. Patients are aware of their disordered eating habits and distinguish eating binges from simple overeating. They are usually unaware of hunger during binges and do not stop eating when satiated. They express fear about not being able to stop eating voluntarily and report that binges end only when nausea or abdominal pain becomes severe, when they are interrupted or fall asleep, or when they induce vomiting.

Binges are usually preceded by depressive moods in which the patient feels sad, lonely, empty, and isolated; or by anxiety states with overwhelming tension. These feelings are usually relieved during the binges, but afterward patients typically report a return of depressive mood with disparaging self-criticism and feelings of guilt.

Binges usually occur in secret. They may last from a few minutes to several hours (typically less than 2 hours, with a median reported time of about 1 hour). Most binges are spontaneous, but some may be planned. The frequency of binges ranges from occasional (two or three times a month) to many times a day. The quantity of food consumed varies but is always large. Bulimics report consumption of 3-27 times the recommended daily allowance for calories on binge days, and some claim to spend in excess of $100 a day on binge foods. The food consumed is usually high in carbohydrates and of a texture that is easily swallowed. Patients often report eating the “junk foods” they ordinarily deny themselves but frequently eat whatever is available. Though high-carbohydrate foods are most commonly consumed, the nutritional content of binge foods varies. Although it is uncommon, some bulimics may eat huge quantities of vegetables, such as 7 pounds of carrots, at a single sitting.

Self-induced vomiting is very common but is not essential for the diagnosis. Some patients maintain normal weight by alternating binges with long periods of fasting, and many exercise excessively. (These patients are often referred to as “exercise bulimics.”) Those who do vomit may use emetics such as ipecac syrup or induce vomiting by activating the gag reflex. Lesions on the back of the hand may be evidence of this. Many report that they no longer need chemical or mechanical stimulants to induce emesis, as they can simply vomit at will. Laxative abuse is commonly associated with bulimia, the use of diuretics is not unusual, and rumination may occur.

Patients with bulimia are usually self-conscious about their behavior and often go to great lengths to conceal it. They are very concerned about their physical appearance, with self-esteem overly dependent on perception of body size and shape. Sexual adjustment may be disturbed, with behavior ranging from promiscuity to restricted sexual activity. A number of other symptoms related to poor impulse control are commonly associated with bulimia, such as alcoholism, drug abuse, stealing, self-mutilation, and suicidal gestures and attempts.

Most patients experience weight fluctuations, with weight typically ranging from slightly underweight to slightly overweight. Other symptoms associated with bulimia include edema of hands and feet, headache, sore throat, painless or painful swelling of parotid and salivary glands, erosion of tooth enamel and severe caries, feelings of fullness, abdominal pain, and lethargy and fatigue. Light-headedness, dizziness, syncope, and seizures may occur if vomiting is severe. Menstrual irregularities are common, but amenorrhea is usually not sustained.

Bulimia is usually not incapacitating except in extreme cases, where binge/purging is a virtual full-time preoccupation. When vomiting is excessive, dehydration and electrolyte imbalances can occur and may result in medical emergencies. Deaths from gastric dilatation and rupture have been reported.