Despite the fact that patients with bulimia nervosa are generally unremarkable in physical appearance and often have no external signs of a disorder when examined physically, many peculiar findings might be present which are as mentioned further.
Bilateral parotid enlargement, largely consequent to non-inflammatory stimulation of the salivary glands might be observed [8].

In patients who are too involved in self-induced vomiting, erosion of the inner surface of teeth, loss of the tooth enamel, periodontal diseases, and extensive caries might be found.
Russell’s sign manifests itself by making the knuckles scarred, calloused and having abrasions as a result of repeated induced vomiting [9]. 

Other dermatological manifestations may include telogen effluvium, acne, xerosis , nail dystrophy, and scarring due to cuts, burns, and other trauma [10]. 

Other vague but helpful findings that reflect the intensity of the disorder include hypotension, bradycardia/tachycardia and hypothermia. Pedal edema, is frequent among patients who have abused diuretics, laxatives, or both; it is also seen in those with protein malnourishment resulting in hypoalbuminemia.

Patients with bulimia nervosa and suffering from the issues of being overweight have increased number of fat folds that aid humidity and maceration along with bacterial and fungal overgrowth, stretch marks striae because of skin overextension and various other problems related to increased weight [10].

• Weight Gain

  OBJECTIVE: Fear of gaining weight is a common obstacle to seeking treatment for bulimia nervosa (BN). We investigated changes in body mass index (BMI) during inpatient treatment for BN in relation to treatment outcome and weight suppression (WS). [ncbi.nlm.nih.gov]

  Eventually, they will become locked into a compulsive cycle of bingeing and purging (getting rid of the food) or resorting to other ways of preventing weight gain. Attempts to break the cycle often fail. [bodywhys.ie]

  Binges lead to self-disgust, which causes purging to prevent weight gain. Purging may include: Forcing oneself to vomit Excessive exercise Using laxatives, enemas, or diuretics (water pills) Purging often brings a sense of relief. [medlineplus.gov]

• Weight Loss

  The overweight or obese patients were clearly entering treatment with two explicit treatment goals—abstinence from bulimic behaviors and weight loss. Our intervention, however, was not designed for weight loss. [dx.doi.org]

  Glucagon-like peptide-1 (GLP-1) receptor agonists, marketed for type 2 diabetes and chronic weight management, produce weight loss in a dose dependent manner and have favorable psychiatric adverse event profiles. [ncbi.nlm.nih.gov]

  These behaviours can become more compulsive and uncontrollable over time, and lead to an obsession with food, thoughts about eating (or not eating), weight loss, dieting and body image. [nedc.com.au]

• Weakness

  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. [healthline.com]

  Muscle weakness: the muscles that hold the bladder in the womb and the bowel, if weakened through poor nutrition and compensatory behaviours, they may prolapse (drop) and surgery will be necessary to repair the muscle Feeling bloated - tiredness Sleeplessness [seedeatingdisorders.org.uk]

  A 14-year-old girl with a history of nonpurging bulimia nervosa (BN) was presented with muscular pain and weakness after several days of fasting and vigorous exercise. [ncbi.nlm.nih.gov]

  Exercise bulimia has dangerous complications, including depression, injury, weak bones, reproductive problems and even cardiac arrest. So it’s incredibly important to seek treatment. [ulifeline.org]

• Fatigue

  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. [healthline.com]

  Physical/Medical Complications Fatigue and lack of energy Amenorrhea (loss of menstruation) and irregular menstruation Dizziness Headaches Dehydration Constipation and diarrhea Shortness of breath Irregular heartbeats Depression Tears of esophagus Hair [mirror-mirror.org]

  An adult female patient with history of bulimia and one uncomplicated pregnancy was admitted to the Gastroenterology Department, due to long lasting dyspeptic symptoms, constipation, major weight loss and fatigue. [ncbi.nlm.nih.gov]

• Collapse

  Through a thematic decomposition of their accounts, we identified six discursive constructions of food: "good/healthy" or "bad/unhealthy," "contaminating body and soul," "collapsed into fat," "pleasurable reward," "comfort," and "fuel for the body." [ncbi.nlm.nih.gov]

  From the moment you wake up in the morning with a burning and dry throat, to the time you collapse into bed at night... Exhausted by the binging, vomiting and lies. Bulimia effects you in 3 extremely damaging ways... [your-bulimia-recovery.com]

  A week later, my lung collapsed. I was in an intensive care unit for weeks after. When I was finally sent home, I was home-bound for months and I was informed I had also became anaemic. [metro.co.uk]

  Service: Braces Adult Orthodontics A collapsed bite or closed bite may cause malocclusion A tongue crib stops a tongue thrust habit in a child Active orthodontics removable braces and Invisalign Alignment of teeth with braces via leveling and aligning [nycdentist.com]

• Bulimia Nervosa

  Symptoms of Bulimia: Someone with bulimia nervosa will suffer many side effects. [disabled-world.com]

  Bulimia Glossary Bulimia Nervosa Glossary of Terms (adapted from medicinenet) is provided below. [psychologistanywhereanytime.com]

  Statistics Bulimia statistics Mental health experts approximate that nearly 24 million people battle with eating disorders like bulimia nervosa. Studies have shown that 1% to 2% of young females meet criteria to be diagnosed with bulimia nervosa. [carolinaeatingdisorders.com]

  Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. [minddisorders.com]

• Overeating

  They may feel a loss of control during a binge, and consume great quantities of food (sometimes over 20,000 calories). After a length of time, the sufferer of bulimia will find that they no longer have control over their binging and purging. [disabled-world.com]

  It may lead to serious health problems over time. For example, vomiting over and over can cause: Stomach acid in the esophagus (the tube that moves food from the mouth to the stomach). This can lead to permanent damage of this area. [medlineplus.gov]

  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. [healthline.com]

• Diarrhea

  They act rapidly and directly to stimulate colonic motility, producing a large volume of watery diarrhea. [jeatdisord.biomedcentral.com]

  Other possible digestive issues include diarrhea, bloating, and constipation. Bloody vomit can occur if continued retching and vomiting result in a tear through the esophagus. [medicalnewstoday.com]

  Physical/Medical Complications Fatigue and lack of energy Amenorrhea (loss of menstruation) and irregular menstruation Dizziness Headaches Dehydration Constipation and diarrhea Shortness of breath Irregular heartbeats Depression Tears of esophagus Hair [mirror-mirror.org]

  Acid can also: irritate or tear your esophagus rupture your esophagus and cause blood in vomit irritate your stomach cause stomachaches, heartburn, and acid reflux damage the intestines and cause bloating, diarrhea, or constipation Putting a finger down [healthline.com]

• Insatiable Hunger

  Primary Meanings of bulimia 1. n a disorder of eating in which people go on eating binges and then feel guilt and depression and self-condemnation 2. n pathologically insatiable hunger (especially when caused by brain lesions) Full Definitions of bulimia [vocabulary.com]

  (noun) pathologically insatiable hunger (especially when caused by brain lesions) (bulimia) (bulimia) 2. [kamusbahasainggris.id]

  An eating disorder characterized by extreme overeating followed by self-induced vomiting. a disorder of eating seen among young women who go on eating binges and then feel guilt and depression and self-condemnation pathologically insatiable hunger (especially [glosbe.com]

• Abdominal Bloating

  Some of the signs and symptoms of the disease include: Dehydration Dry brittle nails and hair Abdominal Bloating Constipation Fatigue Fainting Memory Loss Poor Concentration Irregular heartbeat Dental Erosion Prior to admission of an Eating Disorder Treatment [eatingdisorder.care]

  Symptoms common in anorexia nervosa include amenorrhea, abdominal discomfort, bloating or constipation, and cold intolerance. [ncbi.nlm.nih.gov]

• Hypertension

  All-natural supplements often contain herbal forms of caffeine and ephedrine and have been associated with hypertension and cerebrovascular accident. [emedicine.com]

  METHODS: One hundred fifty-four LRYGB or LAGB patients showing BPD and bulimia traits and type II diabetes, hypertension, and/or sleep apnea (OSAS) voluntarily adhered to DBT (n = 72) or treatment as usual (n = 82) for 12 months after surgery. [ncbi.nlm.nih.gov]

  Publisher Full Text [Surgical treatment of chronic pancreatitis complicated by biliary hypertension]. [unboundmedicine.com]

  Increased risk of cesarean birth Delayed fetal growth Respiratory problems Gestational diabetes Complications during labor Depression Miscarriage Preeclampsia Women who are struggling with bulimia will often gain excess weight, which places them at risk for hypertension [americanpregnancy.org]

• Heart Disease

  Bulimia Nervosa Bulimia nervosa, an eating disorder that involves bingeing on food followed by purging, can cause gum disease, osteoporosis, kidney disease, heart disease, and death. Bulimia affects mostly women and teens. [webmd.com]

  […] buliima and heart disease bulimia and haert disease bulimia andh eart disease bulimia and heart disaese bulimai and heart disease bulimia adn heart disease bluimia and heart disease bulimia nad heart disease bulmiia and heart disease bulimia and hear [frilendemaunawili.blogspot.com]

  Even more seriously, you can become a victim of heart disease and with the lack of nutrients that actually enter your system, you will be prone to osteoporosis, the loss of bone density. [streetdirectory.com]

  disease/high blood pressure/diabetes/osteoporosis reduce/relieve/manage/combat stress enhance/promote relaxation/physical and mental well-being compare anorexia See related entries: Healthy eating habits, Unhealthy eating habits Word Origin late Middle [oxfordlearnersdictionaries.com]

  Low blood pressure and irregular heart rhythms also occur, and the risk of heart failure increases as the disease progresses. [bulimia.com]

• Blurred Vision

  vision Because a bulimic’s weight generally hovers around average or aboveaverage, she can often hide her condition for years. [healthychildren.org]

  Slimming drugs and appetite suppressants used to control appetite and prevent binges may work in the short term but can cause irritability, anxiety attacks, depression, paranoia, constipation, blurred vision and in some cases, psychosis or death. [firststepsed.co.uk]

  Depending on the size of the aneurysm and the area involved, these symptoms can include headaches, neck pain, blurred vision, and speech changes. When a brain aneurysm ruptures, there is bleeding within the brain. [medicinenet.com]

• Suggestibility

  Our results suggest that diminished serotonin activity may trigger some of the cognitive and mood disturbances associated with BN. [ncbi.nlm.nih.gov]

  Findings from a 2007 study suggest that changes in ovarian hormones may increase the risk. [medicalnewstoday.com]

• Fear

  Participants also completed the Fear of Self Questionnaire (FSQ) that evaluates investment in a feared possible identity. [ncbi.nlm.nih.gov]

  There is a powerful and overwhelming fear of gaining weight. [medicalnewstoday.com]

  People with bulimia feel ashamed of their behavior and may feel guilty, however, the fear of gaining weight perpetuates their continued disordered behavior. [weightmatters.co.uk]

  "In my mind [my hand] is like a petri dish. … Otherwise I would spend the day, as I have in the past in my life in the men's room rubbing and scrubbing and scalding… The biggest fear I have is being triggered. [usmagazine.com]

• Hunger

  (especially when caused by brain lesions) Type of: hunger, hungriness a physiological need for food; the consequence of food deprivation [vocabulary.com]

  Modified entries © 2019 by Penguin Random House LLC and HarperCollins Publishers Ltd Word origin [1350–1400; ME ‹ NL ‹ Gk boulīmía extreme hunger, equiv. to bou- intensive prefix (deriv. of bou-, s. of boûs ox) + līm(ós) hunger + -ia -ia] Examples of [collinsdictionary.com]

  "ox-hunger," from bou-, intensive prefix (originally from bous "ox") + limos "hunger;" as a psychological disorder, technically bulemia nervosa. [web.archive.org]

  The term Bulimia comes from the Greek word for ‘ravenous hunger’, and many sufferers report feeling that they have little control over their hunger when they binge. [mirror-mirror.org]

• Anxiety Disorder

  To report observations on the efficacy and tolerability of topiramate in a sample of five patients with severe symptoms of bulimia nervosa and comorbid mood and/or anxiety disorders. [ncbi.nlm.nih.gov]

  Co-occurring mood disorders, anxiety disorders, PTSD, self-injury and personality disorders are also frequently recognized in people with symptoms of bulimia. [timberlineknolls.com]

  Bulimics are much more likely than non-bulimics to have an affective disorder, such as depression or general anxiety disorder. [disabled-world.com]

• Dyslexia

  Chemotherapy Chronic Fatigue Syndrome Chronic Pain Cirrhosis Cocaine Codependency College Colon Cancer Colorectal Cancer Coming Out Crohns Disease Cymbalta Cystic Fibrosis Dads Dementia Depression Diabetes Diverticulitis Divorce Dizziness Down Syndrome Drug Dyslexia [bulimia.supportgroups.com]

• Forgetful

  […] more > ABC Ambassadors Passionate about raising awareness of eating disorders, our team of volunteers support and represent ABC. read more > PLEASE WATCH OUR VIDEO “For me recovery is about being out of your safe zone and feeling proud and liberated, forgetting [anorexiabulimiacare.org.uk]

  Don’t forget that recovery also involves ongoing learning, self-help and peer support. Find out how EDV can help guide and support your recovery: EDV Hub – helpline service providing information, navigation and general support. [eatingdisorders.org.au]

  I’ll never forget their distraught faces as they watched over me. You can recover fully It’s been three years since being hospitalised, and it has been three years since I last made myself sick. [metro.co.uk]

• Insomnia

  She suffered from adverse effects including headaches, tachycardia, anxiety, insomnia, and, finally, grand mal seizures. [ncbi.nlm.nih.gov]

  […] dry, yellow skin infertile, unable to get pregnant kidney failure abnormal heartbeat or heart attack slowed heart rate breathless enlarged glands in the mouth and neck dehydrated tooth pain or tooth decay red eyes hair loss or thinning weight changes insomnia [keltyeatingdisorders.ca]

  Healthy Sex Heart Attack Heart Disease Heartburn Hepatitis C Heroin Herpes High Blood Pressure High Cholesterol Hives Hoarding Hodgkins Lymphoma Huntingtons Disease Hyperthyroidism Hypothyroidism Hysterectomy Incest Survivors Infertility Infidelity Insomnia [bulimia.supportgroups.com]

  […] glands Fainting Choking Dehydration due to vomiting or avoidance of drinking water Headaches Dry skin Heart palpitations Muscle aches and cramps Bloating Chest pain Seizures Irregular periods in women, or a loss of periods Sleep disturbances, including insomnia [priorygroup.com]

• Excitement

  I’m excited. In fact, I’m very excited. I’ve been in a state of frenzy since I walked through the doors and the smell of oil and fat hit my nostrils. I know what I’m doing is going to hurt me, but I don’t care. I want to hurt. [yahoo.com]

  It All Started With a Little Cafe: How One Nonprofit Builds Community and Sustainability By Rochelle Bilow NEDA is excited to share how NEDA Network member, Ophelia's Place, thinks outside the box to raise awareness around eating disorders and body image [nationaleatingdisorders.org]

  […] especially dining out in public Abuse of laxatives, enemas, emetics, diuretics Spends less time with family and friends; becomes more isolated, withdrawn, secretive Stealing food and hoarding it in unusual places, such as in the closet or under the bed Excitability [healthychildren.org]

  There are exciting new studies being done utilizing functional MRIs that reveal there are very real neural processing differences between a normal brain and that of someone with bulimia. [mirror-mirror.org]

  Diet pills taken to excess can cause the body to become overactive and excitable Difficulties in sleeping Heart palpitations and permanent cardiovascular damage You become on edge and jumpy The mind becomes overactive and you become suspicious and agitated [firststepsed.co.uk]

• Difficulty Concentrating

  Difficulties concentrating Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate) Dizziness Fainting/syncope Feeling cold all the time Sleep problems Cuts and calluses across the top [nationaleatingdisorders.org]

  Symptoms of bulimia The binge/purge cycles associated with bulimia can dominate daily life and lead to difficulties in relationships and social situations. [beateatingdisorders.org.uk]

  concentrating Sleeping problems Dehydration Tired, weak, run-down Damage to teeth - sensitive, discoloured. [getselfhelp.co.uk]

• Amenorrhea

  Feeling deeply depressed, agitated or anxious when they can’t work out • Suffering from health problems such as dehydration, exhaustion, injuries, osteoporosis, arthritis • Isolating from others • Overly focused on appearance • Overly self-critical • Amenorrhea [ulifeline.org]

  […] bleeding Fluctuations in weight Constipation due to laxative abuse Dehydration Low potassium levels Calluses or scars on hands or knuckles Bloodshot eyes Imbalanced fluids and/or electrolytes Irregular heartbeat Abdominal pain Menstrual irregularity or amenorrhea [carolinaeatingdisorders.com]

  Physical/Medical Complications Fatigue and lack of energy Amenorrhea (loss of menstruation) and irregular menstruation Dizziness Headaches Dehydration Constipation and diarrhea Shortness of breath Irregular heartbeats Depression Tears of esophagus Hair [mirror-mirror.org]

A comprehensive blood chemistry panel is important for detecting possibly occult metabolic complications. Due to increased vomiting, there are chances of developing hypokalemic metabolic alkalosis. In patients with heavy laxative abuse, normokalemic metabolic acidosis can take place. Other conditions like hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia should also be examined for. Patients with remarkable intravascular depletion can manifest elevated BUN levels (blood urea nitrogen).

Complete blood cell count is used for assessing anemia or any occult hematologic disorders.

Urinalysis may help in finding the urine specific gravity that may reflect the state of hydration.

Co-morbid substance abuse may be checked using a urine toxicology screen [11].

Pregnancy test should be done to rule out a pregnancy in those female patients complaining about amenorrhea.

Hyperamylasemia is seen in about 30% persons with significantly high vomiting because of salivary gland hypersecretion.
An electrocardiogram (ECG) should be done to rule out any type of cardiomyopathies as there are chances of arrhythmias.
A dual energy absorptiometry (DEXA) scan should be done to rule out osteoporosis.

• Hypercholesterolemia

  Cholesterol metabolism in anorexia nervosa and hypercholesterolemia. J Clin Endocrinol Metab. 1979; 38 :325–9. [ PubMed ] [ Google Scholar ] 33. Gold P, Kaye W, Robertson GI, Ebert M. [ncbi.nlm.nih.gov]

  Cholesterol metabolism in anorexia nervosa and hypercholesterolemia. J Clin Endocrinol Metab. 1979;38:325–9. Google Scholar 33. Gold P, Kaye W, Robertson GI, Ebert M. [doi.org]

Bulimia nervosa is managed optimally using a multiple specialty team. A team of healthcare providers is needed to treat bulimia. This includes the primary care provider, nutritionist, psychotherapist, and psychiatrist. Various other specialists might also be needed for these patients depending on other complications.

Main non-pharmacologic treatment for bulimia nervosa includes:

• Cognitive-behavioral therapy (CBT) helps to recognize unsound, negative ideas and behaviors and substitute them with good, positive ones.
• Interpersonal psychotherapy (IPT) addresses difficulties in close relationships, and helps in improving communication and problem-solving skills.
• Nutritional rehabilitation counseling in which the dieticians and health-care providers design a safe eating plan to help get back a healthy weight, achieve normal eating habits and maintain good nutrition.
• Family therapy that helps parents act to stop their teenager from continuing unhealthy eating behavior and aids the teen to get control on their own eating habits. Finally, it helps the family to deal with problems that bulimia can occur on the teen's growth and development and her family.

Medications used in treating bulimia nervosa include the following:

• Fluoxetine is an FDA-approved drug for bulimia nervosa therapy.
• Antidepressants have a vital role in treatment of bulimia; [12] they can help patients with significant associated symptoms like depression, anxiety, or impulsive disorder symptoms.

Most of the people with bulimia recoup, if they are treated earlier in life. Prognosis is better if the illness begins at the time of pubescence. Prognosis is bad if the person has other psychiatric problems too. The results are good if the person gets treatment for these psychiatric problems along with the process of treating bulimia.

Bulimia nervosa is commoner among persons whose occupations or hobbies require rapid gaining and/or losing weight, e.g. wrestlers, competitive bodybuilders [2]. Athletes in sports like running and gymnastics are especially prone to such eating disorders [3].

Media and advertisements endorsing the 'ideal' body are commonly considered to be the major factor in the rise of bulimia. Certain careers such as ballet dancing, modeling, and acting [4] also seem to possess a higher risk for such disorders. In humans, evidence from research suggests an association between polymorphism in ERβ (estrogen receptor β) and bulimia, which suggests that there is some correlation between sex hormones and bulimia nervosa [5].

In the US alone, prevalence of bulimia is 1% [6]. The lifetime prevalence for bulimia is 0.5% in males and 1.5% in females. Just like anorexia, bulimia nervosa occurs largely in women. Many of the reports propose the female-to-male ratio of 10:1.

The mean age of onset is 19.7. Bulimia is 5 times more common in cities compared to rural areas [7]. It occurs more frequently in developed countries.

Bulimia may develop after a very restrictive diet. Sometimes it is seen that binging is triggered due to a stressful event, where food makes one feel comfortable. The sense of guilt and feeling regretful of binging makes one purge so as to prevent weight gain. This marks the beginning of recurrent binging and purging which later becomes a routine.

As bulimia develops, one avoids meals while starting the day, but afterwards the person tends to binge in order to comfort herself, particularly when a stressful day ends.

When one vomits, endorphins are released from the body. Endorphins are natural chemicals which make us feel good. Ultimately, it becomes a habit for the person, to vomit so as to feel good, even when she hasn’t eaten much. Quickly the patients start losing control over this cycle of binging and purging. Regular vomiting, not eating anything, exercising a lot, or abusing laxatives, diuretics, or enemas can ultimately advance to grave, long-term health issues.

Once bulimia becomes a habit, it is very difficult to get back to normal eating without any assistance. This unhealthy eating habit may continue for years prior to the treatment.

There is no known way to prevent bulimia. Starting the treatment as early as possible is the best way to prohibit the progression of this disorder. Having knowledge of signs of bulimia and getting immediate medical attention can help avert long-term problems.

Bulimia nervosa is a kind of eating disorder that is characterized by binging and removing the food, or having a large quantity of food in a small duration followed by attempts to get rid of the food by purging, mostly by vomiting, or using a laxative, diuretic, or stimulant. Few of patients engage into excessive exercising due to huge concerns of body weight [1].

We see that bulimia mainly affects the women in our society. It is difficult to recognize if someone around us is suffering from it. If we pay attention, we come to know that these people have bouts of vomiting after eating or they even induce vomiting by pretending as if something is stuck in the throat. Sometimes you find that mostly their talks revolve around ways of losing weight that might even be unhealthy.

It is difficult for anyone suffering from bulimia to treat themselves but they can build their own treatment plan, like regularly going for the therapy sessions and sticking to the meal plans. It is important that the patient does not separate from friends and family members who wish good health for her. One must know that they always want the best for you and such caring, nurturing relations are good for recovery. Resist urges to weigh repeatedly or check the mirror frequently.

1. Hay PJ, Claudino AM. Bulimia nervosa. Clin Evid (Online). 2010 Jul 19;2010. pii: 1009.
2. Goldfield GS, Blouin AG, Woodside DB. Body image, binge eating, and bulimia nervosa in male bodybuilders. Can J Psychiatry. 2006 Mar;51(3):160-8.
3. Johnson MD. Disordered eating in active and athletic women. Clin Sports Med. 1994 Apr;13(2):355-69.
4. Ravaldi C, Vannacci A, Bolognesi E, Mancini S, et al. Gender role, eating disorder symptoms, and body image concern in ballet dancers. J Psychosom Res. 2006 Oct;61(4):529-35.
5. Hirschberg AL. Sex hormones, appetite and eating behaviour in women. Maturitas. 2012 Mar;71(3):248-56.
6. Hudson, JI, Hirpi, E, Pope, HG, et al. The Prevalence and Correlates of Eating Disorders in National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58.
7. van Son GE, van Hoeken D, Bartelds AI, van Furth EF, Hoek HW. "Urbanisation and the incidence of eating disorders". Br J Psychiatry. 2006 Dec; 189: 562–3.
8. Mandel L, Abai S. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc. 2004 May;135(5):613-6; quiz 655.
9. Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol. 2000 May;39(5):348-53.
10. Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol. 2005;6(3):165-73.
11. Kruger D. Bulimia nervosa: easy to hide but essential to recognize. JAAPA. 2008 Jan;21(1):48-52.
12. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54.