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Bulimia nervosa affects every type of person, regardless of their age, ethnicity, gender, or any other demographic factor. However, it does tend to begin during adolescence. Because of this, and the dangerous health effects the disorder can have, parents should be aware of the signs that bulimia nervosa is developing in their kids.

Eating disorders affect roughly 1.5 percent of women and 0.5 percent of men in the United States at some point during their lifetimes, according to NEDA (National Eating Disorder Association).That may seem like a small percentage, but with a national population of over 311 million, it means over 3 million people struggle with these difficult conditions – more people than Wyoming, Idaho, and Rhode Island combined.

Bulimia nervosa itself affects 1 percent of females and 0.1 percent of males in the United States.  These figures are even higher in the LBGTQ community, although it’s unclear exactly how much higher, as these populations tend to underreport mental health issues and/or have not yet come out, which skews the figures.

How Does It Start?

Although it’s a stereotype that only young women get eating disorders, they can begin at any age. That being said, early adolescence and puberty are the most common age for bulimia nervosa to develop. The median age is coming down; according to some recent studies, the earliest incidences of bulimia nervosa are becoming lower on average in recent years. There have been reliable reports of children as young as 7 or 8 showing designs of disordered eating behaviors.

Whether occurring in childhood, adolescence, or later in life, the causes of bulimia nervosa are almost always a combination of genetic and biological factors, psychological factors, and a socially-mandated idealization of a certain body type (i.e. “skinny” or “thin”). There are some indications that some people are genetically predisposed to engaging in binge eating episodes and subsequent purging behaviors.

The Role of Trauma and PTSD

Trauma is an important triggering factor in many cases of bulimia nervosa. The negative emotions brought on by PTSD can force people into self-destructive “coping” behaviors like binge eating, which releases dopamine, a mood-regulating brain chemical.Traumatic events and those causing PTSD can be caused by an array of different trigger points, including:

  • Physical or sexual abuse
  • An accident, such as a car accident or a slip-and-fall
  • Being the victim of a crime (i.e. being mugged or robbed)
  • Doing through a divorce or a bad breakup
  • Losing a job
  • Losing a loved one or pet
  • Being embarrassed in public
  • Terminal or chronic health issues

PTSD can cause several different psychological effectslike panic attacks or depression. Although it’s associated with a reaction to a recent traumatic event, in many cases, PTSD continues long after the event. Importantly, events that occur during childhood may not manifest as PTSD or related anxiety disorders until many years later.

For example, an adolescent on the swimming team may have to wear a swimsuit in public as their body begins to change because of puberty. If they feel uncomfortable in their body and perceive that people are judging them or thinking they are fat, they may feel traumatized and subconsciously try to counteract those feelings. This can lead to the dieting and binge/purge cycle that defines bulimia nervosa.

Of course, not every case of bulimia nervosa is triggered by past trauma or PTSD.  In some cases, the onset can be a slow burn of combined contributing factors which do not result in a full-blown case until late adolescence or early adulthood.

Behavioral Symptoms and Signs of Bulimia Nervosa

The most important factor in a successful bulimia nervosa recovery is starting as soon as possible. It’s fortunate, then, that there are some distinctive behavioral and physical signs parents can look out for.  While normally the more severe physical symptoms take a long time to appear, the behavioral signs will be present from early on.

  • Body dissatisfaction and attempts to hide its shape

Virtually every instance of bulimia nervosa involves distorted body image and a feeling of being fat, even though that normally isn’t the case (please note that weight loss is not a necessary symptom for a bulimia nervosa diagnosis). This dissatisfaction might present as attempts by the person to hide their body, with baggy clothes or jackets or sweaters. Selfies and other images on social media might be from the neck up only, or otherwise filtered to hide the body.

  • Covering for the purging cycle

Per the official diagnostic guide the DSM-V the key todiagnosing bulimia nervosa is repeated purging after meals and binge-eating episodes. These behaviors might include laxative abuse, obsessive exercising, or fasting, but most commonly are self-induced vomiting.As signs of the binge eating episodes, there may be hoarded food, or food wrappers mysteriously found in the trash. Signs of purging might include lots of wrappers or bottles of diuretics and laxatives as those medicines are often used to purge calories.Another warning sign is if the person always has breath mints, gum, or mouthwash to hide the odor.

  • Frequent trips to the bathroom following meals or in the middle of the night

The classic symptom of bulimia nervosa is forced vomiting after a binge eating episode or meal. This can be in the form of frequent bathroom breaks following meals, or in secret after binge eating. If parents observe that their child frequently goes to the bathroom directly after a meal, or notices them using the bathroom frequently at night, there is an indication he or she is vomiting to purge the calories. Of course, if parents notice the odor of vomit regularly when the child isn’t sick, it warrants investigation.

  • Avoiding eating in public and developing food rituals

Many people with bulimia nervosa engage in fad diets and other forms of calorie restriction because they feel overweight or fat.Because of this, they may eat sparingly at restaurants and other group settings, leaving them hungry. They also will often develop food rituals such as eating their food in a particular order or making sure different foods are not touching on the plate, in some cases as a way to hide how little they are actually eating).

Physical Signs of Bulimia Nervosa

Although the common stereotype of people with eating disorders is that they are severely underweight, this is not as common with bulimia nervosa. Some severe cases of the disorder can cause weight loss, of course, but this is in no way a requirement for a bulimia nervosa diagnosis like it is with anorexia nervosa. However, there are some physical signs of bulimia nervosa which can be more easily identified:

  • Signs related to vomiting

Repeated and frequent vomiting creates distinctive physical consequences over time. The individual’s teeth might develop more cavities and become stained or chipped after exposure to stomach acids. The cheeks and jawline may show unusual swelling, as well, and sore throats and swollen glands are also common.Over time, the fingers and knuckles become stained and calloused after being used to induce vomiting.

  • Signs related to malnutrition and the binge/purge cycle

These symptoms are normally observable only after months or years of disordered eating behaviors. Although bulimia nervosa doesn’t always result in weight loss, the frequent purging can result in a nutritional imbalance and even malnutrition. One of the prominent symptoms of bulimia nervosa, is sudden weight changes, fluctuating up and down as the individual binges and purges. Binge eating episodes often incorporate fatty or sugary foods like pizza or candy, and although they are purged, they can cause weight gain.

The combination of binges on these “empty calories,” along with food avoidance, purging behaviors, and fad diets can result in certain signs of malnutrition. These signs are many – one is a sense of always being cold, which can be combined with the tendency to wear baggy or heavy clothing. Fainting, dizziness, and difficulty concentrating are also clear signs that there is a nutritional imbalance.

Blood and immune system deficiencies also develop after extended cases of bulimia nervosa and lack of necessary nutrition. For example, cuts and bruises may be extremely slow to heal.  In advanced stages, anemia, low blood pressure, and low blood sugar can appear, leading to a sense of being constantly tired and leading to dizziness and fainting episodes. In girls and women, the menstrual cycle may cease, although after bulimia nervosa treatment it normally returns to normal.

Catching the Signs and Symptoms Early Can Make the Difference

None of these physical symptoms will immediately appear; they normally take an extended period of time to progress. As with any progressive mental health disorder, the best way to recover completely is to start early. People with bulimia nervosa often try hard to hide their symptoms and behaviors, and children with the disorder are no different. Parents should contact an eating disorder facility, their family practitioner, or a therapist who specialized in children if they observe any signs of bulimia nervosa. They can help guide the parents to a frank but non-judgmental discussion about the disorder and what steps they can take to secure treatment.


Melissa Spann, PhD, LMHC, CEDS-S

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.