Facing insecurity about our bodies from time to time is part of being human. But what happens when concerns about body image become pervasive — or even all-consuming?

Eating disorders are just one of the many consequences of the overwhelming societal pressure we face to adhere to a certain standard of beauty. In the United States alone, 30 million people suffer from an eating disorder, caused in part by poor body image.

Bulimia nervosa, or simply ‘bulimia,’ is one life-threatening eating disorder that, among other causes, stems from disruptions in body image. Anywhere from 1.1 to 4.2% of women suffer from bulimia in their lifetime — and those figures do not include the men and non-binary folk who are also affected.

Here’s how to tell if a loved one may be struggling with bulimia, how bulimia affects body image and what to do to improve body image and recover from bulimia.

What is bulimia?

We all suffer from occasional negative thoughts about our bodies — just as we all overeat sometimes (for example, on Thanksgiving Day!). But when overeating and negative body image become severe problems, they can combine to form the eating disorder known as bulimia nervosa.

Signs and symptoms of bulimia

Psychiatric professionals use criteria from a handbook known as the DSM-V to diagnose psychological disorders like bulimia. The DSM-V defines bulimia as a combination of recurrent binging (uncontrollable episodes of eating, in a 2-hour window, an abnormally large quantity of food) and purging (compensating for food eaten to prevent weight gain) behaviors. On average, these behaviors must occur at least once a week for three months or more to qualify for a diagnosis of bulimia under the DSM-V criteria.

Purging behaviors used to compensate for binges may include any number of weight control methods, including restricting food intake, vomiting after meals, excessively exercising to ‘burn off’ calories eaten and abusing laxatives. These behaviors can lead to a number of dangerous health consequences — and, when gone unchecked, even death.

Physical signs

A person suffering from bulimia nervosa will likely exhibit some physical signs of their eating disorder. According to the National Eating Disorders Association, some things to watch out for include:

• Noticeable fluctuations in weight, both up and down
• Gastrointestinal complaints, such as stomach cramps and constipation
• Abnormal lab findings, including low electrolytes and/or anemia
• Dizziness and/or fainting; feeling cold all the time
• Dry skin; dry and brittle nails
• Thinning of hair on the scalp and/or growth of fine hair on body
• Erosion of tooth enamel and/or calluses on the finger joints (as a result of self-induced vomiting)
• Irregular or missed menstrual periods

It’s important to note that, unlike patients suffering from anorexia nervosa (another eating disorder characterized by restriction of food intake and extremely low body weight), patients with bulimia typically maintain their normal weight. In fact, some patients with bulimia may even be overweight, despite fervent attempts to purge after a binge. Though we don’t typically picture an overweight person when we think of someone with an eating disorder, eating disorders do not discriminate by size — and a person with an eating disorder, especially bulimia, can appear at any shape or weight.

Emotional and behavioral signs

Eating disorders not only affect the body in negative ways, but also impact the mind. Bulimia manifests in errors of thought and maladaptive coping strategies, among other psychological symptoms. Some emotional and behavioral signs of bulimia to look out for include:

• Hoarding of food and/or food wrappers in strange places; disappearance of large amounts of food in a short amount of time
• Food rituals (such as excessive chewing or cutting food into small bites) and/or avoidance of eating in front of others
• Extreme concern for body weight and appearance; frequent checking of body weight and appearance in the mirror
• Disappearing to the bathroom after meals (i.e. to vomit or abuse laxatives)
• Exercising frequently according to a strict regimen; fear of missing a workout
• Mood swings and/or withdrawal from typical friends and activities

Bulimia and body dysmorphic disorder

Bulimia undoubtedly affects body image, yet so do many other psychological disorders. In particular, body dysmorphic disorder, or ‘body dysmorphia,’ affects many people with and without eating disorders, and is associated with a marked disruption in body image.

What is body dysmorphia?

Someone suffering from body dysmorphia does not see their body in a realistic way. Instead, they are obsessed with a perceived defect in appearance — either a precise complaint about a specific feature, or a general feeling of ugliness. A person with body dysmorphia also attaches negative, often false beliefs to their appearance. For example, one man described by Eating Disorder Hope thought his nose rendered him unlovable.

Because of their perceived defects and the resulting effect on a person’s self-worth, someone with body dysmorphia may go to great lengths to conceal or alter their physical appearance. A sufferer may use heavy make-up to hide their flaws, pick at their skin in an attempt to change a feature or even seek cosmetic surgery to fix a perceived defect in appearance. However, surgeries like these rarely cure body dysmorphia; instead, up to 50% of people with body dysmorphia who undergo surgery develop a new fixation on a previously-unaffected body part.

Bulimia vs. body dysmorphia

While closely related to eating disorders like bulimia, body dysmorphia is not, technically, an eating disorder. Instead, it is associated with other obsessive-compulsive type disorders, such as obsessive-compulsive disorder and hoarding.

Body dysmorphia, much like an eating disorder, deteriorates body image, leading to preoccupation with physical appearance and related distress. However, someone with body dysmorphia does not inherently obsess over their weight and shape or engage in binging and purging behaviors. Thus, while body dysmorphia and bulimia may co-occur in some patients, to have bulimia is not to have body dysmorphic disorder. They are separate disorders that must be treated in different ways.

How bulimia affects body image

Bulimia and negative body image go hand-in-hand — but how does bad body image contribute to the development of bulimia, as well as perpetuate the disorder? Here’s why body image matters so much in the conversation about bulimia nervosa.

What is a healthy body image?

‘Body image’ refers to our thoughts, beliefs and attitudes about our body’s shape, weight and appearance. Many of us struggle with our body image — but believe it or not, we weren’t born hating ourselves! We learned these messages from a mass media determined to perpetuate unrealistic body types and a diet industry profiting off thousands of questionable ‘get-thin-quick’ products and services.

In a perfect world untouched by modern media, we would all have a healthy body image. But what would that look like? Well, you don’t have to love every part of yourself to have a healthy body image — you simply have to accept yourself as you are, even the parts you don’t like.

According to Mirror Mirror, “A person with a healthy body image has an objective, undistorted view of their body and appearance. They do not spend a large amount of time checking their body or perceived flaws, or comparing themselves to others.”

Most importantly, a person with a healthy body image may still feel insecure about some parts of their appearance, but doesn’t let their insecurities get in the way of leading a full, happy life. Their body image does not disrupt their daily activities, including work, school, social interactions and sexual activity.

Causes of negative body image

Distorted, or negative, body image develops when a person sees their body and its perceived flaws in an unrealistic way. Both internal and external factors contribute to negative body image, including but not limited to:

• Childhood experiences. Our body image develops during childhood — and harmful comments from parents, coaches, siblings and bullies can impact our body image for the rest of our lives. In fact, by elementary school, 40-60% of kids already worry that they are ‘too fat!’
• Culture. Every culture defines its own standards of beauty, which affect our body image. In the United States, that standard may be thin and athletic — but other countries prize different body types. Regardless, how well we fit cultural standards of beauty, as well as the cultural messages we receive about our bodies, affect our body image.
• Media exposure. The media, including social media, portrays an unrealistically thin ideal of what makes a person attractive. Few of us can live up to this standard set by the media, but most of us feel some pressure to look this way anyways.
• Personality traits. Some people are more perfectionistic or self-critical than others, putting them at higher risk for negative body image.
• Athletics. Certain sports place a dangerous focus on body shape and weight, encouraging athletes to lose weight in order to improve their performance. For example, wrestlers compete by weight class and may need to ‘cut’ weight, while dancers and gymnasts participate in aesthetic sports where body type matters to coaches, judges and onlookers.

Bulimia and negative body image

Negative body image does not singlehandedly cause bulimia — but, unsurprisingly, people with negative body image are more likely to develop an eating disorder, such as bulimia. As of 2019, body image is the best known predictor of developing anorexia nervosa or bulimia nervosa.

People with negative body image often begin dieting as a means of controlling their weight, yet this dieting can easily spiral out of control into restrictive eating and over-exercising. When a person begins the cycle of binging and purging, ‘harmless’ dieting then becomes bulimia nervosa.

Other risk factors for bulimia

While negative body image is the most important predictor of developing bulimia, it is not the only predicting factor associated with the development of this eating disorder. Other risk factors for bulimia nervosa include:

• Genetics. Studies have shown that having a first-degree relative with an eating disorder increases a person’s risk for developing an eating disorder themselves.
• Mental illness. Patients with a preexisting mood or anxiety disorder — or a first-degree relative with one of these disorders — may be more likely to develop an eating disorder.
• Trauma. People internalize trauma, even when it occurred before they were born. Members of groups who experienced ‘historical trauma,’ such as Native Americans and Jewish Holocaust survivors, may be more likely to develop health problems such as eating disorders.
• Low self-esteem. Poor self-esteem may predispose a person to developing bulimia.In one study, patients with bulimia experienced especially high rates of negative self-evaluation prior to developing the disorder.

Combating negative body image in bulimia

It’s never easy to challenge negative beliefs so deeply rooted in our childhoods and our culture — but it’s imperative to do so in the treatment of bulimia nervosa. Healing from an eating disorder requires you to establish a new, more positive body image — and here’s how.

How is bulimia treated?

Treating negative body image is only one component of treatment for bulimia nervosa. Doctors use a combination of methods, including talk therapy and medication, to treat bulimia safely and effectively.

Nutritional Counseling

Because bulimia disrupts a patient’s relationship with food, nutritional counseling teaches patients to structure and pace meals, and how to adjust calorie intake to an amount necessary to maintain a healthy weight. This counseling may occur on an inpatient or outpatient basis, and be performed by a therapist, nutritionist or registered dietician.

Cognitive-Behavioral Therapy (CBT)

Research supports that CBT is the most effective modality of therapy for bulimia. In CBT, patients learn to restructure negative thoughts and beliefs about their body and to break the cycle of binging and purging behavior through healthier coping strategies.

Medication

Fluoxetine (brand name Prozac) is the only medication approved by the FDA to treat eating disorders. Fluoxetine is a selective serotonin reuptake inhibitor (SRRI), which works by making more serotonin available in the body. This type of medication improves mood and reduces the frequency of binging and purging behaviors; however, it is most effective when used in combination with therapy.

How to improve your body image

Whether or not you struggle with an eating disorder like bulimia, you can take actionable steps to improve your body image today. Here are some activities you might want to try if you’re working on achieving a healthier body image at home.

1. Wear clothing that is comfortable, that fits your body and that brings you joy. Don’t force yourself to wear clothing to mask your shape or hide parts of your body you dislike. Choose clothing based on how comfortable it is and how much you like it — and nothing else!
2. List 5-10 good qualities about yourself that have nothing to do with your body or weight. Your size does not define your worth! So, think of reasons to love yourself that have nothing to do with what you weigh or how you look. For example, are you kind? A good friend? Fun to be around?
3. Focus on what your body can do for you. Rather than judging your body based on how it looks, appreciate your body for all that it does for you. Your body allows you to run, climb, hike, swim, dance, ride a bike — and do all the things you love to do on a daily basis! What does your body do for YOU?
4. Unfollow social media accounts that make you feel bad about yourself. Curate your social media feed so it can be a positive, safe space for you to be yourself without judgment. Unfollow any influencers or fitness accounts that make you feel negatively about your body — and instead, fill your feed with body-positive accounts that embrace your differences.
5. Practice self-care every day. The practice of taking care of yourself helps to generate compassion for yourself and the body you inhabit. A little goes a long way when it comes to self-care, so whether it’s taking a 30-minute bath or writing in your journal for 10, you’ll begin to notice a difference in the way you feel about yourself in no time.

And at the end of the day, there’s no better way for you to make progress healing from bulimia than by reaching out to a licensed therapist.

Here at The Meadowglade, we’re experts at guiding clients toward healthier self-image and helping them develop new coping mechanisms to aid them in their battle with bulimia! Contact us today to learn how we can help.