Jane* was 14 years old when a teacher referred her to my office as the school counselor, with concerns that she’d been late for school. Jane had also been seen to exercise frequently and miss lunch. She had changed her appearance in recent weeks, wearing baggy clothes and returning from toilet breaks with bloodshot and watering eyes.

Although it wasn’t clear at the time, Jane was suffering from an eating disorder known as bulimia nervosa.

(*The name has been changed for confidentiality reasons.)

What is bulimia nervosa?

Bulimia nervosa is a mental health disorder characterized by a cycle of binge eating followed by self-induced vomiting or other weight-control behaviors.

What are the types of bulimia?

There are 2 types of bulimia, both having serious consequences.

Purging type

The person uses compensatory behavior to get rid of the food eaten or control body weight. These behaviors usually involve self-induced vomiting but can also include ingestion of diuretics or laxatives as a means to flush out calories.

Non-purging type

The person uses other compensatory behavior for the same goal (controlling weight), including exercise or fasting to compensate for food consumed.

How is bulimia diagnosed?

A recent US study using self-reported data from adolescents found that bulimia was prevalent in 5.1% of girls and 2.3% of boys of the total sample. This was compared with a national sample of all age groups reporting bulimia was prevalent in 1.5% of females and 0.5% of males.

An international study from 2016 concluded that adolescents were at greatest risk—83% of those diagnosed with bulimia fell into the 12-25 age group.

For a diagnosis of bulimia nervosa, the DSM 5 criteria require the following at least once a week for 3 months:

• Recurrent episodes of binge eating (e.g., within a 2-hour period) of an amount of food larger than what most people would eat in that time and loss of control.
• Recurrent inappropriate weight loss behavior, such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercising.

What are the signs of bulimia in children and teens?

Bulimia starts similarly to anorexia but with the added episodes of binge eating. The bulimia nervosa symptoms and signs to consider as invitations to help include:

Physical

• May be underweight, overweight, or a healthy weight
• Swelling around the cheeks or damage to the teeth from vomiting
• Stomach pains
• Exhaustion

Behavior

• Restricting food intake
• Binge eating followed by weight control behaviors (vomiting, laxatives, or diuretics)
• Not eating with others and going to the bathroom after meals
• Lying about eating, exercise, or weight
• Over-exercising, even with an injury

Psychological

• Unhappy about body image
• Constantly thinking about measuring or weighing self
• Anxiety and avoidance around mealtimes

The binge-purge cycle in bulimia begins with feelings of distress. This is followed by the urge to restrict eating. When feelings of hunger can no longer be tolerated, food consumption beyond the point of discomfort occurs.

The feeling of disgust and anxiety that follows eating leads to weight-control behavior. The cycle ends with feelings of shame leading to further food restriction, and the cycle keeps repeating.

Do bulimics lose weight?

Interestingly, while eating disorders typically revolve around weight loss, people with bulimia often don’t lose weight. When the weight loss behaviors don’t lead to the expected result, the cycle of disgust with the body image continues.

Jane’s teacher checked in with her daily as the girl refused to seek my professional support. The teacher took her aside, saying she had noticed changes in Jane’s mood and tiredness. The teacher was caring and sensitive enough not to raise concerns about Jane’s weight or eating habits, bringing up instead the changes in behavior and signs of distress she was observing.

A few days later, Jane told her teacher that she was worried about how tired and sad she was feeling every day.

Which kids are at risk and what are the causes of bulimia?

The exact causes of bulimia remain unknown. Young people that are already vulnerable due to low self-esteem and body dissatisfaction may be most at risk of developing bulimia.

A study of eating disorders literature found a link between bulimia and depression. Although this was not established to be a cause in all cases, there was a strong link between mood disorders and other risk factors leading to bulimia.

Other common risk factors include:

• Internalizing society’s ideal of being thin—the media’s portrayal of ideal body size can influence many young people’s thoughts about their own body image.
• Biased ways of thinking about food and body shape based on beliefs about being thin
• Pressure to be thin due to occupation or recreational pursuits
• Genetic component (eating disorders in the family)

What is the most effective bulimia nervosa treatment?

A referral from your family doctor can give you access to a team of specialists who will focus on the following treatments for bulimia:

• Cognitive behavior therapy (CBT)—It helps the person restructure unhelpful thoughts and beliefs. With eating disorders, the process involves identifying the thoughts that lead to body dissatisfaction, challenging these thoughts, and then restating them in a more rational way. CBT targets underlying beliefs of low self-worth based on body size and leading to unhelpful thoughts.
• The support of a dietician — This specialist helps set up an appropriate meal plan and educates the bulimic on healthy eating.
• Medication such as antidepressants — It can assist with the recovery by suppressing urges to engage in the binge-purge cycle.

Jane decided to seek professional help with the aid of her trusted teacher and allowed me to contact her parents. When she returned to the school counselor’s office, Jane engaged in weekly sessions to discuss her thoughts. She compared her appearance to that of other girls at school, saying she would never be “as pretty as them.”

Jane said she would often run several laps around the school track before classes when she felt at her ugliest and wouldn’t eat for days. She would raid the fridge at home when she was too weak and hungry. She’d eat until all the food was gone and then purge. We explored what being “ugly” meant to her and started to track her unhelpful beliefs and thoughts throughout the week in a diary.

How to help your child or teen if they show signs of bulimia

Here are some helpful tips:

• Focus on how your child is feeling and show them you’re ready to listen.
• Like Jane, your teen may not want to talk or believe they have a problem, so let them know you are there when they are ready to talk and keep coming back to them.
• Ask if they want to speak to someone else (a teacher, older friend, or family member).
• Let them know you are worried about them and their health.
• Try not to comment on weight, size, or body shape.
• Don’t try to convince them that they are attractive or don’t need to lose weight.
• Don’t try to problem-solve (e.g., “Just stop!”).
• Offer to assist them in getting help from a doctor or online support and even offer to go with them to seek help.

Possible complications of bulimia nervosa

The cycle of ongoing binge eating and purging can result in psychological and medical complications.

A literature review study found that if not addressed early, bulimia can result in:

• Damage to the stomach and intestines
• Constipation, diarrhea, and possibly irritable bowel syndrome (IBS)
• Hormonal problems including menstrual problems in females
• Damage to the eyes, ears, and nose and dental problems from self-induced vomiting
• Fertility and reproductive problems
• Depression or anxiety symptoms

Recovery from bulimia

Sometimes, just being able to have a conversation with your child or teen about your concerns can be enough for them to start on the road to recovery. It’s a long process that involves accepting professional help to assist in the identification and interruption of the thoughts perpetuating the binge-purge cycle. Next comes a plan to eradicate behaviors that restrict food consumption and heal the person’s relationship with food and their body.

Jane was able to consider treatment for her bulimia as she had a trusted teacher who cared enough to take the time to notice that she was in distress. The girl came to therapy weekly to discuss the distressing thoughts that fueled her eating disorder and challenged beliefs about her worth.

It was a long journey, requiring time and effort not only from Jane but also from her parents and friends. She eventually began to see her worth as a person and realized that it was not defined by her weight.