Bulimia and anorexia are two of the most commonly known eating disorders. They are both serious psychiatric conditions that can be life-threatening, and require assessment and treatment from a mental health professional as soon as possible.
What is Bulimia?
Bulimia nervosa, commonly called bulimia, is an eating disorder characterized by its cyclic nature of consuming excessively large amounts of food followed by extreme compensatory behaviors. Examples of extreme compensatory behavior include self-induced vomiting, misuse of laxatives, restriction of calories for a long period after a binge episode, or excessive exercise. Those with bulimia also have negative relationships with their body and self-image, which tends to result in an intense fear of gaining weight and/or a desperate desire to lose weight. Bulimia affects about 6.2 million Americans each year, and is diagnosed in women at disproportionately higher rates than men – about 5x higher. Although the average age of onset for bulimia is 18 years old, diagnoses have been for individuals as young as 6 years old, as well as individuals well into senior citizenship.
Bulimia may be difficult to visually recognize because those with bulimia tend to be average weight (given their height, age, sex, etc.) or just slightly overweight. Therefore, understanding the direct and indirect signs of bulimia are crucial to recognizing a problem in yourself or those around you. Some of the most common signs of bulimia include:
- Repeated episodes of eating abnormally large amounts of food in one sitting
- Evidence of purging behaviors, such as frequent trips to the restroom after meals or smell of vomit
- Appears uncomfortable eating around others
- Frequently tries new diet practices, such as cutting out whole food groups
- Steals or hoards food
- Hides body with baggy clothes
- Frequent checking in the mirror for perceived flaws in appearance
- Creates lifestyle or rituals around making time for binge-and-purge sessions
- “Bulimia teeth” – cavities or discoloration of teeth from vomiting
According to the DSM-5, bulimia is classified as a feeding and eating disorder. The diagnostic criteria for bulimia is:
- Recurrent episodes of binge eating, as characterized by both:
- Eating, in a 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances
- A feeling that one cannot stop eating or control what or how much one is eating
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting or excessive exercise
- The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months
- Self-evaluation is unjustifiably influenced by body shape and weight
- The disturbance does not occur exclusively during episodes of anorexia nervosa
- Specify if:
- Partial remission: After full criteria were previously met, some but not all of the criteria have been met for a sustained period of time
- Full remission: After full criteria were previously met, none of the criteria have been met for a sustained period of time
- Current severity:
- Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week
- Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week
iii. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week
- Extreme: An average of 14 of more episodes of inappropriate compensatory behaviors per week
What is Anorexia?
Anorexia, formally diagnosed as anorexia nervosa, is a life threatening eating disorder characterized by persistent weight loss, difficulties maintaining appropriate body weight (for height, age, etc.), and a distorted body image. Additionally, anorexia may be identified in children if they consistently fail to meet the appropriate weight gain for their age group. Similar to bulimia, disordered eating and behavior in those with anorexia is often most influenced by moderate to severe body dysmorphia and/or an intense fear of gaining weight. The most common form of anorexic behavior is an extreme restriction of calorie intake, but those with anorexia may also practice compulsive exercise or purging via vomiting or laxatives as other ways of controlling calorie intake. According to the National Institute of Mental Health, the lifetime prevalence of anorexia in adults is about 1% and was three times higher among females than males. A meta-analysis of data from studies published between 1966 and 2010 found anorexia to have the highest mortality rate (5.86) when compared to bulimia (1.98) and binge eating disorder (1.92). Additionally, the study found that 1 in 5 of those with anorexia who died committed suicide.
Along with severe emotional and behavioral symptoms of anorexia, there are several physical signs that are related to starvation. In some cases, anorexia may be slightly easier to detect than bulimia because those with anorexia tend to exhibit low body weight, but not all who suffer with the disorder are visibly underweight and some may even look overweight. The consequences of anorexic behavior can lead to serious health problems and death, so it is important to recognize the signs and symptoms of anorexia in any body type. Some of the most common signs of anorexia include:
- Extreme restriction of calorie intake through dieting or fasting
- Excessive exercise
- Self-induced purging through vomiting or misuse of laxatives or diuretics
- Preoccupation with food, such as only eating those low in fat and calories
- Frequently skipping meals, refusing to eat, or denial of hunger
- Frequently commenting about feeling “fat” or being overweight despite weight loss
- Development of strict eating rituals
- Maintaining excessive, rigid exercise regimen despite weather, fatigue, illness, or injury
- (In females) Menstrual irregularities
- Stomach cramps and other gastrointestinal problems
- Dry skin and brittle nails
- Constantly feeling cold
- Teeth cavities and discoloration from vomiting
According to the DSM-5, anorexia is classified as a feeding and eating disorder. The diagnostic criteria for anorexia is:
- Restriction of energy intake relative to requirements, leading to a significant low body weight in the context of age, sex, development trajectory, and physical health
- Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain
- Disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of seriousness of low bodyweight
- Specify whether:
- Restricting type: During the last 3 months, has not regularly engaged in binge-eating or purging
- Binge-eating/purging type: During the last 3 months, has regularly engaged in binge-eating or purging
iii. Partial remission: After full criteria met, low bodyweight has not been met for sustained period, but at least one of the following two criteria still met:
- Intense fear of gaining weight/becoming obese or behavior that interferes with weight gain
- Distrubed by weight and shape
- Full remission: After full criteria met, none of the criteria met for sustained period of time
Difference between Bulimia and Anorexia
These disorders share a few similarities, such as DSM-5 classification as feeding and eating disorders and an intense preoccupation with losing weight/maintaining a low bodyweight. Aside from these similarities, however, bulimia and anorexia have several characteristics that make them distinct from one another. A few of the key differences between the disorders are:
- Once an individual is diagnosed with anorexia, their assessor may further classify their anorexia as the restricting or purging type. Once an individual is diagnosed with bulimia, the only further classification that can be made of their disorder is its severity. Details described in diagnostic criteria sections above.
- Those with anorexia tend to adopt more extreme (normally, calorie restrictive) diets than those with bulimia
- The primary diagnostic criteria of anorexia is a restriction of energy intake, while that of bulimia is recurrent episodes of binge eating followed by compensatory behavior
- Lifetime comorbidity with other core psychiatric disorders (anxiety, mood, impulse control, and substance use disorders) was higher in those with bulimia (94.5%) than those with anorexia (56.2%)
In addition to the key differences listed above, several studies have found notable distinctions between the disorders. One study that aimed to identify retrospective correlates that distinguish anorexia and bulimia found that, when compared to anorexia, those with bulimia reported significantly higher rates of being overweight (real and objective) in adolescence and excessive family importance placed on fitness or staying in shape. Overall, struggling with weight in adolescence proved to be the most influential retrospective correlate in the distinction between bulimic and anorexic participants.
Finally, a separate study sought to compare the eating attitudes, thoughts, behaviors, and relationships with food in participants with anorexia, bulimia, binge eating disorder, or obesity (no eating disorder). The results indicated that while eating attitudes were most dysfunctional in those with anorexia and bulimia, bulimic participants presented this in primarily psychological characteristics, such as impulsivity and anxiety symptoms, which translated into chaotic eating patterns and attitudes. On the other hand, participants with anorexia primarily reported experiencing a stronger necessity to control their environment, as well as inflexible thoughts, perfectionism, and limited social spontaneity – which, altogether, was reflected in their eating attitudes. Regarding their relationship with food, clinical observation of anorexic and bulimic participants also found that those with bulimia experienced more anger, guilt, ambivalence, and incompetence for food compared to those with anorexia. In contrast, most anorexic participants’ relationship with food reflected more apathy towards food or dismissal of it altogether as they reported lower levels of awareness for their disordered eating patterns; they instead, behaved as if they had “overcome” food.