Bulimia nervosa is an eating disorder that’s described as a destructive pattern of eating and purging to control weight. Two of the most prominent behaviors of bulimia are bingeing (eating a lot of food) and purging (self-induced vomiting), but bulimia encompasses so much more than that. It can also take a tremendous emotional toll and lead to severe, life-threatening conditions.

When you think of bulimia, you’re most likely to think of bingeing and purging. However, these aren’t the only symptoms of the disorder. Bulimia can present itself through the following symptoms:

In addition to mental stress, continuous bingeing and purging puts great strain on the body. Unlike anorexia, another type of eating disorder, bulimia doesn’t necessarily have symptoms of significant weight loss. But the effects are still very real.

While characterized as an eating disorder, bulimia is also a mental health disorder that causes a cycle of health concerns. You may experience depression, anxiety, or obsessive-compulsive behaviors. Moodiness and irritability may occur due to lack of vitamins or behaviors that come along with bulimia. For example, constant monitoring of food and weight can become an obsession. Someone may also binge in secret and then hide evidence of food and laxatives. In order to achieve their ideal weight, people may also engage in substance abuse.

Compulsive exercising or preoccupation with appearance are also common symptoms. It’s not unusual for someone with bulimia to spend a lot of time thinking about food and how to control it. In fact, people with bulimia may become quite focused on eating to the exclusion of other activities that they used to enjoy.

Having to keep secrets contributes to the cycle of stress and anxiety. Over time, guilt can build up from keeping secrets from your friends and loved ones. This may also be accompanied by feelings of embarrassment and shame. Suicidal behavior may form as a culmination of the stress and extreme unhealthy body image.

The cycle of bingeing and purging eventually takes a toll on your digestive system. Not only is it physically demanding, but the effects of bulimia can bring on general weakness and fatigue.

A sore throat, stomach pain, or both may be the first obvious physical side effects of bulimia. As the disorder progresses, chronic self-induced vomiting can cause a variety of symptoms in the digestive tract, beginning at the mouth. Over time, the high acid content of vomit can damage teeth and cause enamel erosion, tooth sensitivity, and gum disease. Puffy cheeks or jaws may be noticed secondary to swollen salivary glands.

Acid can also:

Putting a finger down your own throat is one of the most common ways people with bulimia induce vomiting. Doing this over and over can cause callouses on the back of your hand (in the knuckle area) because of your knuckles coming in contact with your incisors. This phenomenon is known as Russell’s sign. The acidity scars the skin on your fingers and hands.

Another way that some people try to rid the body of excessive calories from food is to use diuretics, diet pills, or laxatives. Overuse of these products can make it difficult to have a bowel movement without using them. Misdirected use of diuretics may also damage the kidneys. Over-strained bowel movements can also result in hemorrhoids.

Frequent purging can cause dehydration. This leads to weak muscles and extreme fatigue. It can also throw your electrolytes out of balance and put strain on your heart. This can cause an irregular heartbeat (arrhythmia), and in some severe cases, a weakened heart muscle and heart failure. The electrolytes that tend to go missing from constant vomiting are potassium, magnesium, and sodium.

Bulimia can cause low blood pressure, a weak pulse, and anemia. Vomiting can be a violent event. The sheer force of it can even cause the blood vessels in your eyes to rupture.

The nutritional deficiencies people with bulimia experience can cause a hormonal imbalance. The fatigue can kill your sex drive. Bulimia can interfere with your menstrual cycle or stop it altogether. If the ovaries no longer release eggs, it’s impossible for the sperm to fertilize the egg.

Pregnant women who continue to engage in bingeing and purging behaviors face additional complications for themselves and their babies. These include:

Use of diuretics or laxatives during pregnancy may be harmful to your unborn baby.

The integumentary system includes your hair, skin, and nails. These parts of your body aren’t immune to the effects of bulimia, either. Dehydration from frequent vomiting means that your body doesn’t have enough water. In turn, your hair can become dry and frizzy. You may even experience hair loss.

Dry skin and nails are also a long-term side effect of bulimia. Your skin may become rough and scaly, while your nails turn brittle.