Bulimia Nervosa: What It Is and Who's at Risk

Bulimia nervosa is a type of eating disorder characterized by episodes of binge eating that are then followed by purging behaviors, said Melissa Spann, L.M.H.C., the chief clinical officer of Monte Nido & Affiliates in Miami. Purging may include actions such as abusing laxatives and diuretics, making yourself vomit or overexercising.

Common symptoms of eating disorders in general are reported to be low sexual desire alongside feelings of anger, anxiety, depression and disillusionment. Bulimia is also linked to disordered relationships as sufferers may withdraw from others as their obsession with food becomes all they care about.

People who binge can often feel insecure about controlling themselves, which can lead to brief moments of sexual impulsivity, but mostly there's a lack of enthusiasm for frequent or consistent sexual behavior.

The lack of control during binge episodes is described by sufferers as feeling as though they cannot stop or don't have control over what or how much they eat. Typically, purging takes place at some point after a binge and is motivated by the desire for thinness, weight loss or to "make up" for a binge.

"Bulimia nervosa is actually one of the most common eating disorders," Spann said.

Bulimia nervosa affects people of all ages, body sizes, genders, races and abilities. While it is a common eating disorder, it remains a serious and potentially life-threatening condition.

Are there different types of bulimia nervosa?

Bulimia nervosa does not have different diagnostic types in the way that there are subtypes of anorexia nervosa, Spann explained. However, there are two purge types associated with bulimia nervosa.

Purging is a compensatory behavior, and the first type of purging associated with bulimia nervosa includes actions such as induced vomiting or abusing laxatives or diuretics.

"The other type would be a non-purge type but still the compensatory behavior, so that would be something like bingeing then participating in excessive exercise or not eating, so restriction," she added.

While there are not different types of bulimia nervosa, everyone experiences it differently, so two people diagnosed with bulimia nervosa could face vastly different experiences.

Bulimia nervosa vs. binge eating disorder

Although binge eating disorder is also an eating disorder characterized by episodes of binge eating and may seem similar to bulimia nervosa at a glance, they are quite different.

"The single biggest difference in the simplest terms is that there are no compensatory behaviors associated with binge eating disorder," Spann explained. "Compensatory behaviors are something like purging, vomiting, laxatives, diuretics [and] overexercising—anything to try and 'make up' a binge—versus binge eating disorder, which is marked by distinct episodes of binge eating without the compensatory behavior."

What causes bulimia nervosa?

A number of different factors impact the likelihood of someone developing an eating disorder or bulimia nervosa.

"I often say that diet is the worst of the four-letter words out there, because most eating disorders begin with an individual going on what they would say is a socially acceptable diet and then receiving praise for it, to which then it spirals out of control," Spann said.

A study published in 2016 in Pediatrics journal found that among 14- and 15-year-olds, dieting was the most important predictor of developing an eating disorder. Participants were five times more likely to develop an eating disorder if they dieted moderately and 18 times more likely if they practiced extreme restriction.

Similarly, the National Eating Disorders Association (NEDA) wrote, "The best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness," citing a 2015 study published in the Journal of Child Psychology and Psychiatry.

In addition to the pervasive diets that encourage and praise restrictive eating and weight loss, there are other factors that can impact the onset of an eating disorder. Oftentimes, it is our inherent biological vulnerabilities, combined with "the environment we live in [that] sort of pulls the trigger," according to Spann.

"My philosophical orientation to the onset of eating disorders is from what we call the biopsychosocial model of eating disorder onset and development," she added. "Basically, that means that there are biological factors that contribute to the onset of eating disorders [as well as] psychological and social factors that all sort of combine to lead to the perfect circumstances to develop an eating disorder."

Biological factors

Biological factors that contribute to an increased risk of developing an eating disorder are a history of dieting, having a close relative with an eating disorder or having a close relative with a mental health condition, according to NEDA.

"Studies of families have found that having a first-degree relative, like a parent or sibling, with an eating disorder increases a person's risk of developing an eating disorder," according to the association.

Psychological factors

According to NEDA, some psychological factors that can put someone at risk of having an eating disorder are perfectionism, body image dissatisfaction, a history of an anxiety disorder and behavioral inflexibility.

"Childhood obsessive-compulsive traits, such as perfectionism, having to follow the rules and concern about mistakes were much more common in women who developed eating disorders than women who didn't," the association reported.

Social factors

Social factors associated with developing an eating disorder, such as bulimia nervosa, are weight stigma, bullying or teasing, new exposure to Western culture, loneliness and isolation, and a history of trauma, according to NEDA.

Spann noted that she sees a history of trauma being a significant social risk factor at her practice as well. About 35 percent of clients at her organization are LGBTQIA+, and within this group, Spann said they see higher instances of trauma.

"At some point, eating disorders in general were considered to be a middle-class disease, and we know that's not the case," she said. "There's significant research out of marginalized communities that can tell us that's not true."

Teenage girls from low-income families are 153 percent more likely to become bulimic than girls from wealthier families, according to a paper published in 2011. This study found Black teenagers are 50 percent more likely than white teenagers to have bulimia nervosa, and Black girls and girls from low-income families are often underdiagnosed for bulimia nervosa.

Transgender people also exhibit far higher rates of eating disorders than cisgender people, NEDA reported.

"In a survey of college students, transgender students were significantly more likely than members of any other group to report an eating disorder diagnosis in the past year," the association reported.

Athletes are at high risk

Several studies indicate eating disorders are pervasive among college athletes. In a study published in 1999 in the International Journal of Eating Disorders that surveyed NCAA athletes, more than one-third of female athletes displayed symptoms and attitudes that put them at risk for anorexia nervosa.

Similarly, 35 percent of female and 10 percent of male college athletes were at risk for anorexia nervosa, and 58 percent of female and 38 percent of male college athletes were at risk for bulimia nervosa, according to a 2003 study published by the National Center on Addiction and Substance Abuse.

It's not just college athletes who are at high risk. A study published in 2011 in the Journal of Orthopaedic & Sports Physical Therapy surveyed female high school athletes. About 35 percent reported symptoms of an eating disorder, and these athletes were twice as likely to get injured as their counterparts who did not exhibit disordered eating.

Sports that emphasize diet, appearance, size and weight tend to have more athletes exhibiting disordered eating behaviors. In weight-class sports such as wrestling, rowing and horse racing, and aesthetic sports such as bodybuilding, gymnastics, swimming and diving, more than 33 percent of male athletes and up to 62 percent of female athletes were affected by disorders, NEDA reported.

Stigma increases the risk of developing bulimia nervosa

People who experience discrimination, bullying, violence or teasing for their weight or size are at higher risk for developing bulimia nervosa. While there is a common assumption that people in larger bodies do not have eating disorders, particularly eating disorders such as bulimia nervosa that involve restricting or purging, this is far from true.

"Weight stigma poses a significant threat to psychological and physical health," according to NEDA. "It has been documented as a significant risk factor for depression, low self-esteem and body dissatisfaction." NEDA, citing a 2008 study, reported, "Those who experience weight-based stigmatization engage in more frequent binge eating, are at increased risk for eating disorder symptoms, and are more likely to have a diagnosis of binge eating disorder."

Similarly, 40 percent of overweight girls and 37 percent of overweight boys are teased about their weight by their peers or family, and this teasing often leads to binge eating and extreme weight control measures, according to the study published in 2016 in Pediatrics journal.