Bulimia Nervosa

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Bulimia Nervosa

Bulimia (boo-LEE-me-uh) nervosa often referred to as bulimia is an eating disorder that is distinguished by binging on food and purging it. Girls and women are more likely to have bulimia than boys and men are, but boys and men are underrepresented in treatment-seeking samples. Bulimia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with bulimia. Bulimia can be difficult to detect but that does not mean an individual is not suffering from bulimia. Bulimia is a serious, potentially life-threatening eating disorder, but there is effective treatment can help you feel better about yourself, adopt healthier eating patterns and reverse serious complications.

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Bulimia Nervosa Defined

Bulimia (boo-LEE-me-uh) nervosa is an eating disorder that is distinguished by recurrent episodes of binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain, and self-evaluation that is unduly influenced by body shape and weight. These behaviors must occur, on average, at least once per week for 3 months. An “episode of binge eating” is defined as eating, in a discrete period of time, and amount of food that is definitely larger than most individuals would eat in a similar period of time users similar circumstances. To prevent weight gain, individuals with bulimia also participate in purge behaviors or purging. Many individuals with bulimia nervosa employ several methods to compensate for binge eating. People with bulimia spend a large part of their life doing what they can to control their weight and have a hyperfocus on their body shape and self-evaluation. Their focus on their weight is so severe that it interferes with their life and is dangerous to their physical health. Bulimia is not about food, but related to an inability to handle extreme emotional problems in a healthy manner. The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.

Different Types of Bulimia Nervosa:

There are not separate types of bulimia nervosa, but there are levels of severity. The minimum level of severity is based on the frequency of inappropriate compensatory behaviors. The level of severity may be increased to reflect the other symptoms and the degree of functional disability.

Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.

Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.

Extreme: an average of 14 or more episodes of inappropriate compensatory behaviors per week.

Bulimia Nervosa Causes:

Bulimia nervosa common begins during adolescence or young adulthood. It is rare that it begins before puberty or after the age 40. The onset of this disorder is often associated with experiencing multiple stressful life events. The binge eating frequently begins during or after an episode of dieting to lose weight. Internalization of having a thin body has been found to increase the risk of developing weight concerns, which increase the risk of developing bulimia nervosa. The experience of childhood sexual or physical abuse also puts an individual at risk for developing bulimia nervosa. Childhood obesity and early pubertal maturation increase risk for bulimia nervosa, as well as familial transmission of bulimia nervosa may be present, as well as genetic vulnerabilities. Other aspects associated with increased risk for developing bulimia nervosa are low self-esteem, weight concern, social anxiety disorder, weight concerns, and overanxious disorder of childhood.

Bulimia Nervosa Symptoms:

To be diagnosed with bulimia nervosa, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

  • Recurrent episodes of binge- eating. An episode of binge eating is characterized by both of the following:
    • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating control what or how much one is eating)
  • Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.

There are several symptoms and physical symptoms related to bulimia nervosa. They may include:

  • Being preoccupied with your body shape and weight
  • Living in fear of gaining weight
  • Repeated episodes of eating abnormally large amounts of food in one sitting
  • Feeling a loss of control during bingeing — like you can't stop eating or can't control what you eat
  • Swollen cheeks or jaw area
  • Calluses or scrapes on the knuckles (if using fingers to induce vomiting)
  • Teeth that look clear instead of white and are increasingly sensitive and decaying
  • Broken blood vessels in the eyes
  • Acid reflux, constipation, and other gastrointestinal problems
  • Severe dehydration
  • Forcing yourself to vomit or exercising too much to keep from gaining weight after bingeing
  • Using dietary supplements or herbal products excessively for weight loss
  • Using laxatives, diuretics or enemas after eating when they're not needed
  • Fasting, restricting calories or avoiding certain foods between binges

The severity of binging is dependent on the number of times a week that you purge. Suicide Risk is elevated in bulimia nervosa. It is important that a comprehensive suicide risk assessment is conducted with individual who struggle from this disorder.

How to Approach a Loved One:

There is not a perfect way to approach a loved one that you assume or know is struggling with bulimia. It is very common for people to keep their bingeing and purging a secret. Since they may not physically look like they have an eating disorder (unlike anorexia) it can be more difficult to detect. If you notice that a family member or friend is constantly worrying about being fat, strict dieting or fasting after binging, going to the bathroom right after eating, exercising too much, etc. consider talking to him or her about these issues. Urge them to talk to their doctor. You can not force someone to seek professional care, but you can always offer your support and encouragement. Even though you may not be able to prevent your loved one from developing bulimia, you can still talk about healthier behavior or treatment options.

Types of Bulimia Nervosa Treatment:

There are effective treatments for bulimia nervosa, but there is an increased risk of relapse during periods of high stress or during triggering situations.Combined treatment is also most effective in treating bulimia. It is important to have ongoing therapy or periodic appointments during times of stress as well as nutrition education for continued recovery. Treating bulimia is generally done with a team approach due to the physical aspects that impact the body. The team usually includes dietitians, mental health professionals, and doctors.

Hospitalization and other programs

If a person’s life is in immediate danger or symptoms are severe, the first step to treatment must be in a hospital emergency room. Most individuals that struggle with bulimia can be treated outside of a hospital. If you choose to go to a clinic it is imperative that the clinic specializes in treating eating disorders. Specialized eating disorder programs may offer more-intensive treatment over longer periods of time. Day programs and residential programs are also an option besides full hospitalization, but safety is most important.

Education on Nutrition

An important goal of treatment is having a continuous healthy diet. Dietitians can design an eating plan to help you achieve healthy eating habits to avoid hunger and cravings and to provide good nutrition. Eating regularly and not restricting your food intake is important in overcoming bulimia. The family will likely be involved in helping you maintain normal eating habits because they are also part of your support system.

Psychotherapy

Psychotherapy, also known as talk therapy or psychological counseling, involves discussing your bulimia and related issues with a mental health professional. Psychotherapy is the most common treatment for bulimia and has the greatest research support. Evidence indicates that these types of psychotherapy help improve symptoms of bulimia:

Family-based therapy: Family-based treatment gives the opportunity for the family to understand and realize the roles they are playing in supporting the disordered eating, and suggest ways the family can help the person with bulimia acknowledge the problem and seek out treatment. It helps parents intervene in their adolescents unhealthy eating behaviors.

Individual therapy: One goal of psychotherapy is to normalize eating patterns and behaviors. Cognitive behavioral therapy, specifically enhanced cognitive behavioral therapy, has been shown to help. Cognitive-behavioral therapy will often focus on identifying and altering dysfunctional thought patterns, attitudes and beliefs, which may trigger and perpetuate the person’s eating habits. Another goal is to help change distorted beliefs and thoughts that maintain unhealthy eating habits. Individual therapy can be very helpful in addressing not only disordered eating but also overall emotional health and happiness. The purpose is to address the underlying cognitive and emotional issues that result in bulimia. It allows you to explore close relationships helping to improve your communication and problem-solving skills.

Medications

While there is no medication that necessarily cures bulimia nervosa, there are medications that can help symptoms of bulimia. Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), which may help even if you're not depressed.

Differences Between Common Disorders:

There are other possible causes of either binge eating and regular inappropriate compensatory behaviors. These are common disorders but the differences between them and bulimia nervosa.

  • Anorexia nervosa, binge-eating/purging type- Individuals whose binge-eating behavior occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, binge-eating/ purging type, not bulimia nervosa. If the individual no longer meets criteria for anorexia nervosa binge-eating/ purging type (i.e. the person’s weight is normal), a diagnosis for bulimia nervosa may be met if they meet full criteria for bulimia nervosa for at least 3 months.
  • Binge eating disorder- Some individuals binge eat but do not engage in regular inappropriate compensatory behaviors. In these cases, the diagnosis of binge-eating disorder should be considered.
  • Kleine- Levin syndrome- Kleine- Levin syndrome is a neurological medical condition where there is disturbed eating behavior, but the psychological features of bulimia nervosa like an over concern with the weight and body shape are not present.
  • Major depressive disorder with atypical features- Overeating is common in major depressive disorder, but this disorder does not engage in inappropriate compensatory behaviors. This disorder does not exhibit an excessive concern with body shape and weight characteristics of bulimia nervosa. It is possible to meet criteria for both disorders.
  • Borderline personality disorder- Binge- eating behavior is included in the impulsive behavior criterion that is part of the definition of borderline personality disorder. If the criteria for both personality disorder and bulimia nervosa are met, then you may have both diagnoses.

Resources:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. (5th ed.) Arlington, VA: American Psychiatric Association.

Bulimia nervosa. (2018). Retrieved from https://www.mayoclinic.org/diseases-conditions/bulimia/diagnosis-treatment/drc-20353621

Bulimia nervosa. (2018). Retrieved from https://www.womenshealth.gov/mental-health/mental-health-conditions/eating-disorders/bulimia-nervosa

National Eating Disorder Association. (2018). Retrieved from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia

Understanding Bulimia: Treatment. (2017). Retrieved from https://www.webmd.com/mental-health/eating-disorders/bulimia-nervosa/understanding-bulimia-treatment#2

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