Bulimia Nervosa is a serious eating disorder where a patient eats excessive amounts of food in a short period of time (a binge) and then uses unhealthy methods to prevent weight gain from the binge (a purge). Binges last up to two hours, and people consume thousands of calories and massive portions of numerous sorts of food. People often feel upset after binge eating, and their negative emotional state leads to a purge. The most common way people purge is by forcing themselves to throw up, but people also take laxatives or exercise.
While patients with Anorexia Nervosa stand out because of their low body weight, Bulimia Nervosa is much more difficult to recognize because the individual is not at an unhealthy weight. Even though they purge after a binge, they take in so many calories that they are not able to eliminate all the food before an average of 1,200 calories are absorbed. Additionally, it is rare that new patients are forthcoming about the issue. Emotions surrounding denial and control abound. These patients go to great lengths to hide their struggles. Often, it is concerned family members or friends who are crucial to bringing the true nature of the issue to the attention of medical professionals.
Signs that someone might be struggling with bulimia include large amounts of food missing from the pantry and refrigerator or multiple empty food containers appearing in the trash. These patients also have multiple rules around food. They frequently refuse to eat in public and prefer to eat very little in the presence of others. People often focus on fad diets and restrict the kinds of foods they eat. They disappear after eating to purge and often use mouthwash or gum to mask the smells from vomiting.
Causes and Risk Factors
Bulimia Nervosa is about 10 times as common in women as it is in men. The disorder is most common in adolescence and young adulthood, and appears in 1-1.5% of women in this age range. Unfortunately, men are much less likely to come forward for treatment than women.
Negative emotional states
A negative view of one’s self and a desire for a sense of control set the stage for Bulimia Nervosa. This state often arises from a weight being an issue early in childhood, such as being overweight as a child, having overweight or obese parents, or having an environment that puts a strong focus on the child’s weight or physical appearance. These people tend to be driven for perfection, impulsive, and very critical of themselves. Patients are also more likely to have suffered physical or sexual abuse as children. The characteristic restrictive eating patterns that occur between binges and purges are part of the individual’s effort to feel a sense of control by categorizing certain foods as “acceptable” and staunchly avoiding others.
Stuck in a cycle
When people are stressed, they are vulnerable to falling out of their rigid system of eating and starting a binge. This is where their uncompromising belief system about food and eating comes into play. Once they begin to binge, they feel they have broken their self-imposed rules regarding food, and, instead of moderating, throw all their rules away and lose themselves in a whirlwind of eating. This leads to feelings of guilt and, ultimately, purging behavior.
Bulimia Nervosa more commonly appears in the most modernized cultures, such as the United States, Canada, Europe, Australia, and Japan. These cultures idealize being thin, and it is often socially acceptable to have an unhealthy focus on body image. When adolescents grow up in a culture like this, it puts a lot of pressure on them to become thin. Some people take these cultural values too seriously and want to stay thin no matter what it takes. Bulimia Nervosa is also more common in several sports and jobs, such as modeling, acting, running, ballet, gymnastics, and wrestling.
About 30% of patients with Bulimia Nervosa will also have a Substance Use Disorder at some point in their lives. These usually involve either alcohol or stimulants, which people often start using to suppress appetite. Anxiety disorders, especially Social Anxiety Disorder, are also quite common. Additionally, Bulimia Nervosa is associated with Borderline Personality Disorder. Mood disturbances are very common in these patients and usually appear as Major Depressive Disorder and Bipolar Disorder. These mood disorders often subside when Bulimia Nervosa is successfully treated.
Diagnosing Bulimia Nervosa
Making the diagnosis
Patients with Bulimia Nervosa have episodes where they eat an excessive amount of food that is larger than most people could eat during a short period of time (less than 2 hours). They feel out of control, and they can’t stop eating after they start. The episode only ends when they are so full that they are in pain. This is referred to as a “binge”. After a period of binge eating, these people will almost immediately use methods to relieve the pain of being full and the worry of weight gain. This is called a “purge”. People purge by forcing themselves to vomit (the most common method), using laxatives and diuretics, or excessively exercising.
People become very skilled at making themselves vomit, and many eventually become able to throw up at will. Patients who also have diabetes may skip insulin doses to reduce the weight gained from eating. Others illegally obtain thyroid hormones (normally intended to treat hypothyroidism) to take to prevent weight gain. At times when they are not binge eating or purging, their diet is still quite limited, and they focus on low-calorie foods. To make the diagnosis, these cycles have to happen at least once a week for three months.
These patients are dissatisfied with their body appearance and weight. Their fear of gaining weight is very similar to that in patients with Anorexia Nervosa. The cycles of binge eating and purging are full of confused feelings about control. Additionally, people have a great deal of shame associated with their actions. They go to great efforts to hide their binge eating and purging. Low mood, negative feelings about body image, stress, and periods of low food intake are the most frequent triggers of binges.
Bulimia versus Anorexia versus Binge Eating Disorder
The key difference between Bulimia Nervosa and the Binge-eating/Purging subtype of Anorexia Nervosa is the weight. People with Bulimia Nervosa are not underweight. They have a Body Mass Index (BMI) that is either in the normal (18.5- 24) or overweight (25-29) range. About 10-15% of patients with Bulimia Nervosa will also be diagnosed with Anorexia Nervosa at some point in their lives.
Even more confusing is trying to tell the difference between Bulimia Nervosa and Binge Eating Disorder. After binges, people with Bulimia Nervosa do things like vomit, take laxatives, or exercise excessively to avoid gaining weight. In contrast, those with Binge Eating Disorder take no such steps.
The severity of the disorder is based on the average number of purges in a week. People with a mild condition purge only one to three times a week. In the most extreme cases, however, purges can occur more than 14 times in a week.
Treating Bulimia Nervosa
General treatment principles
Unlike patients with Anorexia Nervosa, who frequently require a short stay in the hospital at the beginning of treatment, people with Bulimia Nervosa rarely need to go to the hospital because they are not dangerously underweight. Hospitalization is only necessary if patients are suicidal or acutely sick from malnutrition or other consequences from binge eating and purging. Day hospital programs are necessary less often than with other eating disorders, but for patients who are failing first line treatments, they can be life-saving. They are intensive outpatient therapy programs where patients spend the majority of the daytime at a program with focused individual and group therapy focusing on body perception and behavioral strategies.
Usually the most effective form of treatment for Bulimia Nervosa is a combination of medication and Cognitive Behavioral Therapy. Medication alone is only about half as effective as psychotherapy alone. Motivation and severity of the disorder are the biggest predictors of success from treatment. Overall, treatment for Bulimia Nervosa is very effective, with about 50% of patients in remission five years after beginning treatment and 73% in remission after seven years.
Cognitive Behavioral Therapy
CBT is the most effective form of therapy for Bulimia Nervosa. Over 20 weeks, CBT focuses on changing the unhealthy attitudes towards eating that these patients harbor in an effort to reduce the frequency of binge eating and purging. The first stage of CBT consists of psychoeducation about the disorder. People learn to monitor their illness through journals that chronicle their eating and how frequently they binge and purge.
In the second stage, patients begin to address the harmful eating patterns and body image concepts. They practice moving outside of their restrictive eating habits and explore less rigid feeding rituals. The last few sessions focus on solidifying gains made in therapy. With CBT alone, 45% of patients stop binge eating and purging by the end of treatment. After one round of CBT, roughly one third to one half of patients fall back to their old ways within four months and will need additional treatment.
Regular meetings with a registered dietitian are very helpful in addressing eating changes during the initial course of CBT. With the guidance of an experienced dietitian, these patients explore the motivating factors and triggers behind binges. They develop more regular eating patterns using detailed food journals. The work done in conjunction with a dietitian complements that done in CBT.
Antidepressants are the front line medications for treatment of Bulimia Nervosa. The most effective type is Selective Serotonin Reuptake Inhibitors (SSRIs). Although SSRIs can be used as the primary treatment for Bulimia Nervosa, they are more often combined with CBT and are most effective this way. Prozac (fluoxetine) decreases episodes of binge eating and purging within just a month of starting the medication. Antidepressants such as Celexa (citalopram) and Zoloft (sertraline) have also shown promise in treating Bulimia Nervosa, but Prozac remains the only medication that is approved by the Food and Drug Administration for this purpose.
Managing Bulimia Nervosa
Raising a child in an environment that does not put much pressure on body image helps guard against Bulimia Nervosa. Approach the topics of diet and exercise in a frame of maintaining health rather than achieving a certain appearance.
Multiple medical issues
People tend to first come to medical attention with general gastrointestinal issues, such as feeling bloated, constipation, and belly pain. Constipation can occur from starving the digestive system of nutrition, and persistent use of laxatives can damage the intestines and also lead to chronic constipation. Repeated disturbance of the digestive system can also leave masses of undigested food in the intestines which also contribute to constipation.
A notorious marker for frequent, self-induced vomiting is damage to teeth, including loss of enamel and chipping. People also develop calluses on the backs of their hands from stomach acid and rubbing on teeth when inducing vomiting. The most dangerous consequence is low levels of potassium in the body, which can lead to hearth rhythm disturbances and potentially sudden death. Repeated vomiting can also cause serious tears in the throat that can bleed quickly enough to be life threatening. Vomiting also causes the saliva glands in the cheeks to enlarge, giving a puffy facial appearance.
Binge eating can stretch the stomach to tearing, which is a medical emergency. Binges can also cause the body to become resistant to insulin and lead to type II diabetes. Patients who abuse diuretics can have swelling of their hands and feet when they stop taking those medications. Women can have irregular menstrual periods as well.
Beware of relapses
After successful treatment of Bulimia Nervosa, patients can slip back into their old binge and purge cycles even after being free for an extended period of time. It may be beneficial to see treatment not as a having a defined end but rather as something to return to from time to time when needed. Be aware of personal triggers and situations that might lead to binge eating and risk a return to the cycle.