Bulimia nervosa is shockingly common, although its widespread presence might not be as well-known as it should be. About 4.7 million women and girls and 1.5 million men and boys live bulimia nervosa, meaning that about 1.5 percent of the female population and 0.5 percent of the male population are living with the disorder in the United States alone.

Many of the disordered behaviors and other symptoms of BN are prominent and well-known, such as the characteristic binge and purge cycle. On the other hand, there are several “hidden symptoms” of bulimia nervosa that aren’t as obvious. That makes them no less dangerous than the more popularized signs, and they still often necessitate bulimia nervosa treatment.

And that treatment is essential, to be sure. Prolonged BN behaviors can lead to a variety of physical health consequences as well as a worsening of mental health difficulties. Education is the key to understanding preventing and treating eating disorders.

Take a look at some of the lesser-known behaviors associated with bulimia nervosa:

Sudden, new food restrictions like veganism or a new carb-free diet

Bulimia nervosa often appears alongside a history of fad dieting and other forms of food restriction. Sometimes they may not binge for several weeks while attempting to lose weight through new food intake regimes, as might be observed with anorexia nervosa. Dietary restrictions are common with both disorders, and yet these restrictions might not be obvious. They might be masquerading as lifestyle choices.

Various kinds of food restrictions are taken on for moral or religious reasons. Veganism, for example, continues to grow in popularity in the US and across the world, which means avoiding all animal-related products, including eggs and dairy. Vegetarianism, slightly less restrictive, has been popular for decades and even centuries.

Some people have medical reasons such as allergies to stay away from foods that contain gluten (as an example), while others use it as a way to surreptitiously reduce their food intake. When occurring as a genuine lifestyle choice and not as a cover for disordered food restrictions, things like an all-vegan diet are laudable. Unfortunately, they can also be used as excuses to avoid certain kinds of food in a socially acceptable way, which can worsen a disorder like bulimia nervosa.

Some people with bulimia nervosa feel uncomfortable eating with other people in social settings, but this can bring up uneasy questions with their tablemates. By saying they are a vegetarian, vegan, or that they’re allergic to certain foods is an easy way to make others believe there is a logical reason why the person is not eating.

Many people do suffer from food allergies, such as allergies to wheat gluten, and these allergies can mean a more restricted diet. Of course, food allergies and bulimia nervosa can both exist in the same person. People who enter a bulimia treatment center that claims to have these allergies are tested by a physician to validate those claims to avoid any unnecessary dietary restrictions.

Increasingly irrational behavior and choices made without thinking them through

In addition to compulsive, disorder behaviors, bulimia nervosa is also known to bring with it impulsive, irrational actions. Many eating disorder treatment centers attempt to treat irrational thoughts and bulimia nervosa at the same time;they’re interrelated and treating one while ignoring the other is counterproductive. Someone who acts on an impulse will seem to completely disregard what would normally be rational thought. For example, the individual may:

Eating much more food in a single setting than is comfortable
Exercise beyond the point of exhaustion, pain, or injury
Suddenly feeling angry or sad and lashing out
Risky choices such as sexual or intoxicant addiction
Making sudden life changes without a plan
Self-harm or suicide

Long-term nutritional imbalance, which is a result of the binge/purge cycle and consistent dieting, can wreak havoc on the brain. It becomes more difficult for people to think clearly and rationally, and impulsive actions might increase the longer disordered eating behaviors continue. Stress factors that might be dealt with in a healthy fashion can instead trigger impulsive behaviors. For example, the stress from a difficult time at work might wear on a person, so they binge eat, ingesting a lot of calories, and then purge to eliminate the food from their system when guilt about the binge sets in.

Frequently trying out new diets and weight loss methods

According to a recent study performed by The Centers for Disease Control, between 2013 and 2016 stated 49.1% of Americans are dieting or taken other steps to lose weight within the past six months. Certainly, this statistic points to the obesity crisis in the United States but also indicates a seemingly “normal” behavior that can be used to cover an eating disorder like bulimia nervosa.

Preoccupation with calorie counting and weight loss is almost always present in cases of bulimia nervosa; they are the primary fears that lead to purging calories after meals and binges. People with BN often try every new diet that comes along and spend a lot of time browsing weight-loss sites or fitness programs.The causes of this fear of weight gain are variable – most people with bulimia nervosa experience a mixture of environmental, genetic, and peer pressure factors that inform the eating disorder. However, frequent dieting is almost always a precursor to BN. A few things the individual may do include:

Trying out new diet pills and supplements regularly
Obsessively watching fitness programs on TV or social media
Always trying the newest fad diet like paleo
Regular fasting or extreme “juice cleanses”

These kinds of behaviors might seem innocuous to friends and family, especially if the individual is attempting to hide them. When most people decide to lose some weight, they may spend a fair amount of time trying different diet or workout plans or methods. On the other hand, a consistent and obsessive series of dieting actions, abuse of diet pills and supplements, and excessive exercise, especially when the person is not overweight (in a medical sense), is a clear sign that there may be a problem.

More Common Symptoms of Bulimia Nervosa

None of the above “hidden symptoms” is enough on its own to make a professional diagnosis of bulimia nervosa, although there is cause for concern if any of them appear. For families and friends of someone who might have bulimia nervosa, it’s important to learn more about the disorder before taking action to secure help. To better determine if someone needs bulimia nervosa treatment, here are some of the more conventional symptoms of bulimia nervosa:

Distorted Body Image and Obsession with Weight

A dissatisfaction with one’s body, also known as body dysphoria, is among the most prominent symptoms of bulimia nervosa and most other eating disorders, according to NEDA.A person suffering from BN may spend hours stressing over how their clothing fits, how much they weigh, or how they look in the mirror. This generally goes far beyond the feelings of dissatisfaction everyone faces from time to time. For example, they might look in the mirror and see themselves as 30 pounds overweight even when their doctor thinks they are too thin and should actually add some weight.

Binging and Purging

Binging and purging are the classic behavioral symptoms of bulimia nervosa and the ones most laypeople are familiar with. First, a binge-eating episode happens, in which a person will heat more food than they need in a short period, usually fatty or sugary “junk food.” This is followed by an attempt to purge the calories; most often this is through self-induced vomiting, but other purging methods include taking diuretics and diet pills or exercising on an extreme level to burn as many calories as possible. These behaviors usually cause guilt, and every attempt is made to hide them. For instance, the individual may binge on foods while alone and hide the fact they are exercising by staying up and doing it through the night.

Eating In Secret

It’s common for people with bulimia to feel uncomfortable eating in public or with other people. There is usually considerable guilt and shame associated with binging and purging as well.Because of this, people with BN might eat sparingly around others and then binge eat in secret. In some cases, this is done in an effort to prevent loved ones from seeing there is a problem.

The common perception of bulimia nervosa is one of an emaciated young white woman. This, unfortunately, gives the false impression that people who have this condition all look the same. Many people with BN are of “normal” weight or even overweight, and although many sources indicate it’s underreported, BN occurs frequently in all races and genders.

How to Find Help for Bulimia Nervosa Recovery

The secrecy surrounding many people’s cases of bulimia nervosa, and the feeling of shame about disordered actions, often prevent people from reaching out for the bulimia nervosa treatment they need. Because of this, those people closest to the individual may have to help them secure that help. To do that, families should get familiar with both major symptoms and the lesser-known behaviors that are involved with this eating disorder.

Family members, friends, and other people close to the individual with BN can help in a variety of ways, but no matter what steps are taken, it’s essential not to antagonize them. A gentle but firm approach is best. Some of the things to do may include:

Educate yourself on the symptoms and behaviors associated with the disorder
Research the different treatment options available
Never be judgmental or condescending
Approach the individual gently about the situation and possibly getting help
Schedule a discussion with a doctor, therapist, or treatment center to secure a diagnosis and plan next steps

Clementine is an adolescent-focused group of eating disorder treatment facilities that treat individuals with eating disorders ranging from anorexia nervosa and bulimia nervosa to binge eating disorder. Our facilities provide compassionate care in a comfortable environment where patients can build a healthier relationship with food, themselves, and others. We treat our clients as people first, and patients second.

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.

Hidden Signs and Symptoms of Bulimia Nervosa