Anorexia vs. Bulimia: What’s the Difference?

Eating disorders are usually characterized by an intense preoccupation with food. Many people who have an eating disorder also express dissatisfaction with their body image.

Other symptoms are often specific to the individual condition.

Anorexia

Anorexia often stems from a distorted body image, which may result from emotional trauma, depression, or anxiety. Some people may view extreme dieting or weight loss as a way to regain control in their lives.

There are many different emotional, behavioral, and physical symptoms that can signal anorexia.

The physical symptoms can be severe and life-threatening. They include:

• severe weight loss
• insomnia
• dehydration
• constipation
• weakness and fatigue
• dizziness and fainting
• thinning and breaking hair
• bluish tinge to the fingers
• dry, yellowish skin
• inability to tolerate cold
• amenorrhea, or absence of menstruation
• downy hair on the body, arms, and face
• arrhythmia, or irregular heartbeat

Someone with anorexia may exhibit certain behavioral changes before physical symptoms are noticeable. This includes:

• skipping meals
• lying about how much food they’ve eaten
• eating only certain “safe” — usually low-calorie — foods
• adopting unusual eating habits, like sorting food on the plate or cutting food into tiny pieces
• talking badly about their body
• trying to hide their body with baggy clothes
• avoiding situations that could involve eating in front of other people, which can result in social withdrawal
• avoiding situations where their body would be revealed, like the beach
• extreme exercising, which may take the form of exercising for too long or too intensely, like an hour-long jog after eating a salad

Emotional symptoms of anorexia may increase as the disorder progresses. They include:

• poor self-esteem and body image
• irritability, agitation, or other mood changes
• social isolation
• depression
• anxiety

Bulimia

Someone with bulimia may develop an unhealthy relationship to food over time. They may get caught up in damaging cycles of binge eating and then panic about the calories they’ve consumed. This may lead to extreme behaviors to prevent weight gain.

There are two different types of bulimia. The attempts to purge are used to differentiate them. The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) now refers to attempts to purge as “inappropriate compensatory behaviors”:

• Purging bulimia. Someone with this type will regularly induce vomiting after binge eating. They may also misuse diuretics, laxatives, or enemas.
• Non-purging bulimia. Instead of purging, someone with this type may fast or engage in extreme exercise to prevent weight gain after a binge.

Many people with bulimia will experience anxiety because their eating behavior is out of control.

As with anorexia, there are many different emotional, behavioral, and physical symptoms that can signal bulimia.

The physical symptoms can be severe and life-threatening. They include:

• weight that increases and decreases in significant amounts, between 5 and 20 pounds in a week
• chapped or cracked lips due to dehydration
• bloodshot eyes, or eyes with busted blood vessels
• callouses, sores, or scars on the knuckles from inducing vomiting
• mouth sensitivity, likely due to eroding tooth enamel and receding gums
• swollen lymph nodes

Someone with bulimia may exhibit certain behavioral changes before physical symptoms are noticeable. This includes:

• constantly worrying about weight or appearance
• eating to the point of discomfort
• going to the bathroom immediately after eating
• exercising too much, especially after they’ve eaten a lot in one sitting
• restricting calories or avoiding certain foods
• not wanting to eat in front of others

Emotional symptoms may increase as the disorder progresses. They include:

• poor self-esteem and body image
• irritability, agitation, or other mood changes
• social isolation
• depression
• anxiety

It isn’t clear what causes anorexia or bulimia to develop. Many medical experts believe it may be due to a combination of complex biological, psychological, and environmental factors.

These include:

• Genetics. According to a 2011 study, you may be more likely to develop an eating disorder if you have a family member who has one. This may be because of a genetic predisposition to traits associated with eating disorders, such as perfectionism. More research is needed to determine whether there’s truly a genetic link.
• Emotional well-being. People who have experienced trauma or have mental health conditions, such as anxiety or depression, may be more likely to develop an eating disorder. Feelings of stress and low self-esteem may also contribute to these behaviors.
• Societal pressures. The current Western ideal of body image, self-worth, and success equated with thinness can perpetuate the desire to achieve this body type. This may be emphasized further by pressure from the media and peers.

If your doctor suspects that you have an eating disorder, they’ll run several tests to help make a diagnosis. These tests can also assess any related complications.

The first step will be a physical exam. Your doctor will weigh you to determine your body mass index (BMI). They’ll likely look at your past history to see how your weight has fluctuated over time. Your doctor will likely ask about your eating and exercise habits. They may also ask you to complete a mental health questionnaire.

At this stage, your doctor will likely order lab tests. This can help rule out other causes of weight loss. It can also monitor your overall health to make sure that no complications have occurred as a result of a possible eating disorder.

If the tests reveal no other medical causes for your symptoms, your doctor may refer you to a therapist for outpatient treatment. They may also refer you to a nutritionist to help you get your diet back on track.

If severe complications have occurred, your doctor may recommend that you get inpatient treatment instead. This will allow your doctor or another medical professional to monitor your progress. They can also watch for signs of further complications.

In either case, your therapist may be the one to actually diagnose a specific eating disorder after talking about your relationship with food and weight.

Diagnostic criteria

There are different criteria that the DSM-5 uses to diagnose anorexia or bulimia.

The criteria required to diagnose anorexia is:

• restricting food intake to maintain a weight below the average weight for your age, height, and overall build
• an intense fear of gaining weight or becoming fat
• connecting your weight with your worth or other distorted perceptions about body image

The criteria required to diagnose bulimia is:

• recurrent episodes of binge eating
• recurrent inappropriate compensatory behaviors — like excessive exercise, self-induced vomiting, fasting, or misuse of laxatives — to prevent weight gain
• bingeing and inappropriate compensatory behaviors both occurring an average of at least once per week, for at least three months
• connecting your weight with your worth or other distorted perceptions about body image

There’s no quick cure for an eating disorder. But there are a number of treatments available to treat both anorexia and bulimia.

Your doctor may recommend a combination of talk therapies, prescription medications, and rehabilitation to treat either condition.

The overall goal of treatment is to:

• address the underlying cause of the condition
• improve your relationship with food
• modify any unhealthy behaviors

If you’re concerned about your eating behavior and don’t already have a mental healthcare provider, you can view doctors in your area through the Healthline FindCare tool.

Medication

According to a 2005 study, medication has shown little efficacy for the treatment of anorexia.

However, of the few trials conducted, there’s evidence to suggest that:

• Olanzapine (Zyprexa) may stimulate appetite and encourage eating.
• Antidepressant selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac) and sertraline (Zoloft), can help treat depression and OCD, which could be a side effect of or even cause the eating disorder.

Medicinal options for bulimia appear to be a little more promising. The 2005 study indicates a number of medications may be effective in treating this disorder.

They include:

• SSRIs like fluoxetine (Prozac) can help treat underlying depression, anxiety, or OCD, and reduce bingeing-purging cycles.
• Monoamine oxidase inhibitors like buspirone (Buspar) can help decrease anxiety and reduce bingeing-purging cycles.
• Tricyclic antidepressants like Imipramine (Tofranil) and desipramine (Norpramin) can help reduce bingeing-purging cycles.
• Antiemetic medications like ondansetron (Zofran) can help reduce purging.

Therapy

Cognitive behavioral therapy (CBT) uses a combination of talk therapy and behavioral modification techniques. It may involve addressing past trauma, which could have caused a need for control or low self-esteem. CBT can also involve questioning your motivations for extreme weight loss. Your therapist will also help you develop practical, healthy ways to deal with your triggers.

Family therapy may be recommended for adolescents and children. It aims to improve communication between you and your parents, as well as teach your parents how to best support you in your recovery.

Your therapist or doctor may also recommend support groups. In these groups, you can talk with others who have experienced eating disorders. This can provide you with a community of people who understand your experience and can offer helpful insight.

Outpatient vs. inpatient

Eating disorders are treated in both outpatient or inpatient settings.

For many, outpatient treatment is the preferred approach. You’ll see your doctor, therapist, and nutritionist regularly, but you can resume your daily life. You won’t have to miss substantial amounts of work or school. You can sleep in the comforts of your own home.

Sometimes, inpatient treatment is required. In these cases, you’ll be hospitalized or placed in a live-in treatment program designed to help you overcome your disorder.

Inpatient treatment may be necessary if:

• You haven’t complied with outpatient treatment.
• Outpatient treatment hasn’t been effective.
• You show signs of excessively misusing diet pills, laxatives, or diuretics.
• Your weight is less than or equal to 70 percent of your healthy body weight, putting you at risk for severe complications.
• You’re experiencing severe depression or anxiety.
• You’re demonstrating suicidal behaviors.

If left untreated, anorexia and bulimia can lead to life-threatening complications.

Anorexia

Over time, anorexia can cause:

• anemia
• electrolyte imbalance
• arrhythmia
• bone loss
• kidney failure
• heart failure

In severe cases, death may occur. This is possible even if you aren’t yet underweight. It can result from arrhythmia or an imbalance of electrolytes.

Bulimia

Over time, bulimia can cause:

• tooth decay
• inflamed or damaged esophagus
• inflamed glands near the cheeks
• ulcers
• pancreatitis
• arrhythmia
• kidney failure
• heart failure

In severe cases, death may occur. This is possible even if you aren’t underweight. It can result from arrhythmia or organ failure.

Eating disorders can be treated through a combination of behavioral modifications, therapy, and medication. Recovery is a continuous process.

Because eating disorders revolve around food — which is impossible to avoid — recovery can be difficult. Relapsing is possible.

Your therapist may recommend “maintenance” appointments every few months. These appointments can help reduce your risk for relapse and help you stay on track with your treatment plan. They also allow your therapist or doctor to adjust treatment as needed.

It can be difficult for friends and family to approach someone they love with an eating disorder. They may not know what to say, or worry about isolating the person.

If you notice that someone you love is exhibiting signs of an eating disorder, however, speak up. Sometimes people with eating disorders are afraid or unable to ask for help, so you’ll need to extend the olive branch.

When approaching a loved one, you should:

• Pick a private location where you can both talk openly without distractions.
• Choose a time when neither of you will be rushed.
• Come from a loving place instead of an accusatory one.
• Explain why you’re concerned, without judging or criticizing. If possible, refer to specific situations and elaborate on why it caused concern.
• Share that you love them and want to help however they may need.
• Be prepared for some denial, defensiveness, or resistance. Some people may get mad and lash out. If this is the case, try to stay calm and focused.
• Be patient, and let them know that if they don’t want help now, you’ll be there if anything changes.
• Go into the conversation knowing some solutions, but don’t suggest them off the bat. Only share resources if they’re open to taking next steps.
• Encourage them to get help. Offer to help them find a therapist or go with them to the doctor if they’re scared. A doctor’s visit is crucial to help someone with an eating disorder get on track and to make sure they’re getting the treatment they need.
• Focus on their feelings instead of physical descriptions.

There are also a few things that you should avoid doing:

• Don’t comment on their appearance, especially as it relates to weight.
• Don’t shame someone about their potential disorder. To avoid this, use “I” statements like “I worry about you” instead of “you” statements like “You’re making yourself sick for no reason.”
• Don’t give medical advice you aren’t equipped to give. Saying things like, “Your life is great, you have no reason to be depressed” or “You’re gorgeous, you don’t need to lose weight,” do nothing to address the problem.
• Don’t try to force someone into treatment. Ultimatums and added pressure don’t work. Unless you’re the parent of a minor, you can’t make someone go into treatment. By doing so, you’ll only strain the relationship and take away a stem of support when they need it most.

If you’re a minor and you have a friend who you believe has an eating disorder, you can go to their parents to express your concern. Sometimes peers can pick up on things that parents don’t, or see behaviors that they hide from their parents. Their parents may be able to get your friend the help they need.

For support, contact the National Eating Disorders Association’s Helpline at 800-931-2237. For 24-hour support, text “NEDA” to 741741.