Bulimia Nervosa: Symptoms, Causes, and Treatment

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What is Bulimia Nervosa?

Bulimia nervosa, also called bulimia, is an eating disorder characterized by binge eating followed by purging. Binge eating means eating a large amount of food in a short amount of time. Purging is the attempt to get rid of the food consumed. This may be done by vomiting or taking laxatives. Other efforts to lose weight may include the use of diuretics, excessive exercise, or water fasting. Most people with bulimia are at a normal weight, though it may fluctuate a bit (Wikipedia contributors, 2019).

Bulimia is frequently associated with other mental disorders, such as anxiety, depression, and alcohol or drug abuse. Bulimia affected around 3.6 million people worldwide in 2015. About 1% of young women have bulimia at a given point in time and about 2-3% of women have the condition at some point in their lives. It is more common in the developed world. Bulimia is about nine times more likely to occur in women than men. Among women, it is more common in young adults. Bulimia was named and first described by the British psychiatrist Gerald Russell in 1979 (Wikipedia contributors, 2019).

Picture listing symptoms of bulimia
Symptoms of bulimia (Source: National Women’s Health Information Center, Public Domain)

Symptoms of Bulimia Nervosa (National Eating Disorders Association, n.d.) (Smith, et al., 2019)

Physical

  • Frequent fluctuations in weight,by 10 pounds or more, due to alternating bingeing and purging.
  • Not underweight.Men and women with bulimia are usually normal weight or slightly overweight. Being underweight while purging might indicate a purging type of anorexia.
  • Using the bathroom frequently after meals
  • Stomach cramps, other gastrointestinal complaints, such as heartburn, constipation, etc.
  • Trouble concentrating
  • Abnormal lab findings – anemia, low thyroid and hormone levels, low potassium, low blood cell counts
  • Dizziness and fainting
  • Feeling cold all the time
  • Sleep problems
  • Calluses or scars on knuckles or hands from sticking fingers down their throat to induce vomiting
  • Dry skin
  • Dry and brittle nails
  • Fine hair on the body
  • Thinning of hair on the head, and dry and brittle hair
  • Discolored teeth from exposure to stomach acid when throwing up. May look yellow, ragged, or clear.
  • Muscle weakness
  • Yellow skin (in context of eating large amounts of carrots)
  • Cold, mottled hands and feet or swelling of feet
  • Menstrual irregularities
  • Swollen glands in neck and face
  • Poor wound healing
  • Impaired immune functioning

Emotional and Behavioral

  • Being preoccupied with your body shape and weight
  • Frequent checking in the mirror for perceived flaws in appearance
  • Lack of control over eating. Unable to stop eating until the point of physical discomfort and pain.
  • Evidence of binge eating, including the disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
  • Going to the bathroom after meals. Frequently disappearing after meals to throw up. Running water to disguise sounds of vomiting.
  • Signs and/or smells of vomiting which may be tried to be covered up with excessive amounts of mouthwash, mints, and gum
  • Presence of wrappers or packages of laxatives or diuretics
  • Excessive exercising after eating. Typical activities include high-intensity calorie burners such as running or aerobics, despite weather, fatigue, illness, or injury.
  • Develops food rituals, e.g., excessive chewing, doesn’t allow foods to be touched
  • Skips meals or takes small portions of food at regular meals
  • Cutting out of entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
  • Fear of eating in public or with others
  • Steals or hoards food in strange places
  • Drinks excessive amounts of water or non-caloric beverages
  • Hides body with baggy clothes
  • Social withdrawal
  • Extreme mood swings

Causes of Bulimia Nervosa (Sadock, et al., 2017)

The exact cause of bulimia is not known. Low self-esteem and concerns about weight and body image may play major roles. You may use eating as an emotional release, bingeing and purging when you feel angry, depressed, stressed, or anxious.

Factors that increase your risk of bulimia may include:

  • Genetic and Biologic Factors.Genetics play a role in the development of bulimia nervosa, as evidenced by twin and family studies. Individuals with a family history of bulimia nervosa, mood disorder, substance abuse or dependence, or obesity are at higher risk for developing bulimia. Being overweight as a child or teen may increase the risk.
  • Developmental Factors.The experience of going through puberty and experiencing changes to body shape and weight may serve as a major stressor for some, triggering or worsening body dissatisfaction and low self-esteem. Weight-related teasing and bullying may become increasingly prevalent at this time, as well, exacerbating the issue. Finally, a number of major social and psychological transitions occur throughout adolescence, including identity and role formation, increasing independence from parents, and the initiation of romantic relationships. These stressors and others may work to increase the risk of this disorder.
  • Psychological Factors. They exhibit high levels of novelty seeking and impulsivity. They also tend to display elevated levels of harm avoidance, negative emotionally, and stress reactivity. Weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, and overanxious disorder of childhood are associated with increased risk for the development of bulimia nervosa. Strong negative emotions may play a role in triggering individual binge episodes in individuals with the disorder, as well, thus acting as maintenance factors in the illness. The cycle of binge eating and purging often becomes self-sustaining in bulimia nervosa. Individuals with bulimia nervosa tend to restrict their food intake outside of binge episodes, which puts them at increased risk for episodes of overeating. In turn, after experiencing a binge episode and the resulting compensatory behaviors, individuals often renew their commitment to restrictive eating in an attempt to avoid future overeating episodes. Thus, this cycle tends to become self-perpetuating and works to maintain the disorder.
  • Environmental and Social Factors. Participation in certain activities in which weight is emphasized may increase the probability of developing bulimia. Ballet, gymnastics, modeling, and weight-restricted sports like wrestling or light-weight rowing may lead to preoccupation with body form and unhealthy attempts to control weight. The cultural ideal of thinness, perpetuated by the media, may fuel the overvaluation of shape and weight. Individuals who experienced childhood sexual or physical abuse are at increased risk for developing bulimia nervosa.

Diagnosis of Bulimia Nervosa

According to DSM-5, the diagnostic criteria for bulimia are (American Psychiatric Association, 2013):

  • 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 or 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.

Thus, there are three essential features of bulimia nervosa: (1) Recurrent episodes of binge eating, (2) Recurrent inappropriate compensatory behaviors to prevent weight gain, and (3) Self-evaluation that is unduly influenced by body shape and weight. To qualify for the diagnosis, the binge eating and inappropriate compensatory behaviors must occur, on average, at least once per week for 3 months (American Psychiatric Association, 2013).

Treatment of Bulimia Nervosa (Mayo Clinic Staff, 2018) (WebMD Medical Reference, 2018)

The goals of the treatment of bulimia nervosa are straightforward. The binge-eating and inappropriate compensatory behaviors should cease, and self-esteem should become more appropriately based on factors other than shape and weight (Tasman, et al., 2015).

Psychotherapy

Cognitive-behavioral therapy (CBT) has demonstrated efficacy, with 40-60% of individuals becoming symptom-free following treatment and most others reporting symptom reduction. By using CBT people record how much food they eat and periods of vomiting with the purpose of identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular basis. CBT helps you normalize your eating patterns and identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones.

Family-based treatment might help parents to offer support and guidance to their teenager to stop unhealthy eating behaviors and regain control over his or her eating, and to help the family mitigate the problems that bulimia can pose to the family and the teen’s development.

Interpersonal psychotherapy addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills.

Medications

Antidepressants are helpful in conjunction with psychotherapy. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), is the only antidepressant specifically approved by the Food and Drug Administration to treat bulimia. It is helpful even if you’re not depressed. Other SSRI antidepressants like sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) can also be effective.

Nutrition

Eating regularly and not restricting your food intake is important in overcoming bulimia. A nutrient-dense, sugar-free diet may help avoid binge eating. Eliminating alcohol, caffeine, and cigarettes can help a great deal. Eat a balanced diet supplemented by vitamins and minerals.

Hospitalization

If symptoms are severe, with complications, you may need treatment in a hospital. Some centers offer day treatment programs.

References

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.

Mayo Clinic Staff, 2018. Bulimia nervosa. [Online]
Available at: https://www.mayoclinic.org/diseases-conditions/bulimia/symptoms-causes/syc-20353615
[Accessed 4 Nov 2019].

National Eating Disorders Association, n.d. Bulimia nervosa. [Online]
Available at: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia
[Accessed 4 Nov 2019].

Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.

Smith, M., Robinson, L. & Segal, J., 2019. Bulimia Nervosa. [Online]
Available at: https://www.helpguide.org/articles/eating-disorders/bulimia-nervosa.htm
[Accessed 4 Nov 2019].

Tasman, A. et al. eds., 2015. Psychiatry. 4th ed. Oxford: Wiley Blackwell.

WebMD Medical Reference, 2018. Bulimia Nervosa. [Online]
Available at: https://www.webmd.com/mental-health/eating-disorders/bulimia-nervosa/mental-health-bulimia-nervosa#1
[Accessed 4 Nov 2019].

Wikipedia contributors, 2019. Bulimia nervosa. [Online]
Available at: https://en.wikipedia.org/w/index.php?title=Bulimia_nervosa&oldid=923599368
[Accessed 4 Nov 2019].

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Bulimia Nervosa: Symptoms, Causes, and Treatment
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Bulimia Nervosa: Symptoms, Causes, and Treatment
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Bulimia nervosa, also called bulimia, is a psychological eating disorder characterized by binge eating followed by purging.
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