Anorexia nervosa, bulimia nervosa, and binge eating disorder share some commonalities in symptoms, but some aspects differ. Keep in mind, that every individual’s experience of an eating disorder varies from person-to-person and each individual experiences an eating disorder to a different degree. The longer or more severe the eating disorder, the more likely the person will exhibit more of the symptoms below.
This outline has been specifically designed to help you understand both the general symptoms of eating disorders (indicated by bullets) and the differences between anorexia nervosa, bulimia nervosa, and binge eating disorder (explained in the boxes).
Additionally, the symptoms are summarized under four categories: physical, cognitive-emotional, behavioral, and social. Some of these symptoms overlap in categories. The point of summarizing these symptoms under these categories is to show how an eating disorder affects the whole person – physically, emotionally, cognitively, behaviorally, and socially.
P H Y S I C A L
· Body shape
Anorexics – Are severely underweight (- 15% under expected body weight). Their BMI (Body Mass Index) is under 17.5. Despite being thin, they continue to restrict food intake or diet.
Bulimics - Tend to be normal to slightly overweight. They develop rapid weight fluctuations. In some cases, a bulimic client can be underweight if they are restricting caloric intake.
Bingers – Tend to be overweight and typically fluctuate in body weight. They frequently diet, but fail to keep excess weight off.
· Damage to body organs and functioning
Anorexics – Malnutrition leads to damage to the organs, vitamin and mineral deficiencies, cardiac irregularities, muscle depletion, bone loss, and an increase in the risk for fractures.
Bulimics – Destruction of the teeth and gums, rupture of the esophagus, damage to the lining of the stomach, vitamin and mineral deficiencies, electrolyte imbalance* (- an alteration to the normal chemical balance in the blood, such as with potassium, calcium, magnesium, and sodium, affecting the body’s functioning), cardiac irregularities, gastrointestinal damage, and aspiration pneumonia due to purging.
Bulimics and Bingers – If overweight, coronary heart disease, type two diabetes, and metabolic syndrome.
· Medical signs for concern
Anorexics – Low weight, irregular or slow heartbeat, low blood pressure, slow pulse rate, and abnormal blood counts.
Bulimics – Irregular electrolytes, cardiac irregularities, and abnormal blood counts.
Bingers – Obesity, high blood pressure, high cholesterol, and abnormal blood counts.
· Observable physical symptoms
Anorexics - Feel cold even when temperature is normal. Their hands are cold to touch. They may exhibit blue nail beds, brittle nails, have poor circulation and poor capillary refill, dry skin, and thinning hair, but growth of soft, downy hair to keep body warm.
Bulimics - Dry skin, bloating, swollen salivary glands in the cheeks, and bruises on the knuckles or hands.
Bingers - Bloating, abdominal swelling, and swollen hands and feet.
· Other physical symptoms
Anorexics – Dehydration, constipation, weakened immune system, dizziness or fainting, and hypoglycemia (- a condition resulting from low levels of glucose in the blood, with the primary problem being too little glucose in the blood going to the brain to maintain proper brain functioning).
Bulimics – Dehydration, sores in the mouth and throat, and abnormal bowel functioning.
· Special note for females
Anorexics – Stoppage or irregular menstruation.
Bulimics and Bingers – May experience irregular menses.
C O G N I T I V E - E M O T I O N A L
- Feelings of depression, anxiety, fatigue, and powerlessness
- Intense feelings of guilt
Anorexics – Feel extremely guilty even with the slightest perceived transgression of food, such as by eating one bite of an “unsafe” food.
Bulimics and Bingers – Self-loathing characterized by feelings of guilt,
self-disgust, and remorse after a binge and/or purge.
- Need for reconciliation or cleansing from perceived guilt
Anorexics – Punish themselves by restricting food intake even more and/or exercising even longer. By punishing themselves in this way, they feel cleansed.
Bulimics and Bingers – Feel amends after purging and/or dieting.
- Low self-esteem resulting from feelings of inadequacy and inferiority
- Self-critical and negative, self-defeating thought patterns
- Need for acceptance and validation
Anorexics – The intense need for acceptance, approval, and admiration is paramount in everything they do. This is why they tend to be perfectionists, and why they are compliant and accommodating. They work toward goals with relentless determination and sacrifice (including dieting).
Bulimics - Exhibit a strong self-defeating internal concept with a need to compensate through gaining approval, validation and acceptance from others.
Bingers – Typically have a martyr self-concept. They give their all to their perceived responsibilities of taking care of others and ensuring their happiness, but afterwards only feel drained and unappreciated.
· Impaired ability to think clearly and make logical and rational decisions (due to altered brain chemistry resulting from malnutrition, bingeing, and purging)
· Very aware of somatic cues, despite anorexics denying hunger cues and bulimics and bingers disregarding fullness cues
Anorexics – Have an intense fear of becoming “fat,” and think they must avoid it at all costs. They have a distorted sense of what is considered overweight, both for themselves and others.
Bulimics - Share the preoccupation with anorexics of wanting to be thin. They have a distorted sense of their own body image. Bulimics often see themselves as larger than they really are.
Bingers – Feel self-disgust at their condition, yet helpless to change it. They often minimize or deny the impact their weight has on their life. Binge eaters often display a distorted sense of their body image, seeing themselves as smaller than they really appear.
- Preoccupied with thoughts of food, weight, and appearance
Anorexics – May compulsively critique their body/body parts for flaws in the mirror.
Anorexics – Their mood is usually flat and they lack emotional expression.
Bulimics – They usually have a fluctuating mood pattern.
Bingers – Tend to minimize their mood/emotional state. They often mask their true feelings by putting on a “jolly face” for everyone.
- Fear of being found out with regard to their eating disorder
B E H A V I O R A L
- Unhealthy coping behaviors to deal with stress, anxiety, and emotional conflict
Anorexics – Restrict food intake or diet. Additionally, they may restrict fluids, excessively exercise, and/or purge.
Bulimics – Binge and use purging techniques (such as vomiting, abusing laxatives and diuretics, and enemas) and/or non-purging behaviors (such as, fasting, dieting, and exercising) to compensate for food intake.
Bingers - Binge or compulsively overeat without purging.
- Abnormal eating behaviors
Anorexics – Label food as “safe” and “unsafe,” and strive to only eat “safe” food. They may refuse to eat or offer excuses not to eat. They have very rigid diets and may have peculiar eating behaviors, such as cutting food into very small pieces, eating unusually slowly, picking at food without eating it, and chewing food then spitting it out.
Bulimics and Bingers – May appear to eat food normally when with others, but binge alone in secret. During binges they eat food rapidly in short periods of time until uncomfortably full or graze on food constantly throughout the day without feeling satisfied.
Anorexics – May secretly dispose of food.
Bulimics – Are secretive about their bingeing and purging.
Bingers – Tend be binge alone in secret. They may secretively hide or hoard food.
- Rigid control verses impulsivity
Anorexics – Report an intense fear of losing control with food and other aspects of their life. Their control over food gives them a false sense of security that they can control other aspects of their life.
Bulimics and Bingers – Both report a pressing need to satisfy their immediate physical needs resulting in impulsivity and difficulty setting limits. They report feeling helpless in exerting control over their unhealthy behaviors. During a binge they usually feel unable to voluntarily stop. This impulsivity may be expressed through excessive shopping/spending, substance abuse, gambling, and/or promiscuity.
- Difficulty expressing emotions verbally
Anorexics – Additionally, have difficulty concentrating due to malnutrition.
- Hostility/irritability towards others
- Obsessive thinking and compulsive behaviors
- Self-alienation and feelings of isolation and loneliness
- Prefer to eat alone to avoid attention, embarrassment, or shame
- Exhibit a tendency towards a passive-aggressive communication style
- Difficulty forming and maintaining relationships
Anorexics – Usually are dependent and avoidant in their relationships. They tend to exhibit enmeshment in certain key relationships, often with the mother.
Bulimics – Typically exhibit disengagement from the family dynamic. The bulimic client is often identified as the scapegoat in the family or the “acting out” member. They often exhibit intense, short-lived personal relationships, consistent with the tendency to engage in impulsive behaviors.
Bingers – Usually are co-dependent or have hostile-dependent relationships.
Anorexics – Coupled with a lower sex drive due to malnutrition, they tend to experience elevated sexual anxiety resulting in limited or no sexual intimacy.
Bulimics – In their impulsivity, they tend to be sexually active, even promiscuous.
Bingers – Despite impulsive tendencies, their shame regarding their overweight condition makes them feel self-conscious about their appearance, and therefore, they are reluctant to engage in sexual activity.