Introduction to Bulimia Nervosa

Bulimia is a devastating, food focused, psychological disorder that can be life threatening if left untreated. It is typically displayed as a vicious and ongoing cycle of bingeing and purging food.

In the binge phase, someone will uncontrollably consume a large amount of food in a very short period of time. Often these will be poor food choices that are high in saturated fat, or very high in sugar such as pizza or donuts. If you could picture someone aggressively searching through their fridge and pantry, before loading the kitchen table up with junk food and sitting down to rapidly consume large portions, then this wouldn’t be an image too far from the truth. Bulimics wouldn’t have trouble consuming an entire tub of ice cream or multiple packets of chips in one sitting.

After exhibiting such eating patterns, someone suffering from bulimia will become saturated with guilt and disgust and then feel the need to force themselves to vomit or expel the food from their body, using medication like laxatives. This is the purge phase, and is usually done in an effort to avoid any weight gain. In the mind of a bulimic, there is a never-ending battle between the desire to eat and the desire to avoid weight gain.

The action of overeating, feeling incredibly guilty, and then purging can often be an outlet if you’re not coping well with or negative experiences or situations in your life. It is much like someone turning to alcohol or drugs as an escape route from their reality. 

Other paths used to also avoid weight gain include:

• Extreme exercise following the process of binge eating – Because of the unpleasant nature of vomiting, some bulimics choose to engage in a high level of exercise in order to burn the calories from the food they just binged on. Because the foods that they binged on contain little nutritional value, the body often does not have the energy to keep up with such high activity, and severe fatigue and sickness can result. 
• Taking laxatives – With the knowledge that laxatives increase bowel movements and the convenience of swallowing a pill, or even chocolate laxatives, bulimics often find this to be an easy option to lose weight. However, the continual use of laxatives can place a lot of stress on the body and result in dizziness, dehydration and inflammation in the body. More serious complications of long term laxative abuse includes the body’s inability to expel faeces (loss of haustra). This can come about from the use of laxatives more than three times a week and for a longer period than one year.  
• Use of enemas -These are considered as mechanical laxatives as they are fluids introduced directly into the anus, used to expel faeces from the bowel. This is quite an unpleasant procedure that can cause bloating, pain in the abdominal region, bleeding and cramping.
• Taking diuretics -These include pills that help to expel fluid from the body by increasing urination. Diuretics are popular in the dieting world as they help to lose weight. Unfortunately, these pills contain many chemicals that have their own harsh side effects such as skin rashes, dizziness and fatigue. Diuretics can be dangerous as they work to remove water from the body and can result in dehydration, lightheadedness, loss of vital electrolytes and even fainting.
• Extreme dieting or fasting -Bulimia is not just recognized as excessive eating, but also includes actions taken as a result of that eating. Feelings of guilt can turn to the feeling of need to starve oneself because of prior reckless eating and weight gain from calories.

According to the American Addiction Centers “Surveys show a rate of approximately1.5 percent of the US female population and 0.5 percent of the male population has experienced bulimia in their lifetimes. These percentages translate to 4.7 million females and 1.5 million males. ”

With many people feeling too ashamed to seek medical attention, these figures are no doubt much higher than what’s shown on paper.

Causes of Bulimia Nervosa

If someone is suffering from bulimia, their binge eating is usually (but not always) triggered by emotions such as sadness and/ or stress when reminded of a particular situation or event. Depression is a strong underlying factor linked to eating disorders. Bulimia can be a common condition amongst those that experience bullying, feelings of worthlessness or loneliness, are in abusive relationships or experience other forms of belittlement. 

The factors that lead to bulimia are incredibly complex and vary from case to case. Often the thought process of a bulimic is that they’re incredibly embarrassed and ashamed for their actions, especially if caught in the act of eating copious amounts of food. Their thought patterns are extremely destructive, often viewing themselves as incredibly weak, fat or disgusting.  

For someone that has very low self-esteem, lack of confidence or have body-issues related to their appearance, they are more at risk of developing an eating disorder. The rise of social media and the illusion of perfection as displayed in photographs has also seen a rise in conditions such as bulimia.

Warning Signs and Symptoms

If you’re concerned that someone close to you may be suffering from bulimia, you should look for the following signs:

• Obsession with body weight and appearance.
• Negative and self-critical comments surrounding their image.
• Abnormal and excessive exercising.
• Finding ‘secret’ stashes of food around the house or excessive junk food wrappers in the bin.
• Visiting the bathroom directly after eating or making constant trips to the bathroom.
• Unusual defensive behavior around the discussion of their eating habits or weight.

Loss of nutrients from consistent purging

Over time, frequent vomiting can result in a lack of nutrients being distributed and available for all the systems in your body. This includes calories, vitamins and minerals, and protein for growth and repair of all cells and tissues.

On top of nutrients lost in vomiting, nutritional levels are often very low to begin with in the types of food binged on, and can be described as very refined junk food.

When the body does not receive an adequate intake of vitamins and minerals from the diet, there can be a multitude of complications, as the body has trouble carrying out its every-day functions. Many vitamins and minerals can only be obtained from food, and the body cannot produce these on its own.

Common signs of malnutrition from excessive vomiting, use of laxatives, diuretics or enemas include:

• Constant fatigue – With food being the main source of fuel for the body, constantly vomiting that food back up, takes away much needed fuel to function. You may feel like you’ve not had enough sleep and have zero energy in the body to go about your day and complete normal tasks.
• Irritability – Many vitamins and minerals are responsible for brain function and mood. However vomiting can cause a major imbalance in chemicals, leading to unexplained bouts of anger or negative emotions. This can only enhance the feelings of helplessness, and a feeling that there is no way out of your situation.
• Muscle weakness – Potassium is an important electrolyte often lost in vomiting. Potassium plays an important role in muscle function, with symptoms of an imbalance including cramping and uncontrollable spasms. Along with fatigue, you may feel you have no strength in your muscles, and persistently low energy.
• Hair loss -Due to lack of intake of nutrients such as iron, zinc and certain B vitamins, hair loss is a common sign of malnutrition. Deficiencies in these groups of nutrients can affect the hair structure and result in the hair growing weak and thin, causing hair to fall out.
• Depression– While depression can be a strong underlying factor in bulimics, some vitamins such as vitamin D have been heavily linked to depression. Sufficient levels of vitamin D may not be obtained through diet in those that frequently vomit. Furthermore, as bulimics are known to isolate themselves from the outside world, they may also not be obtaining enough vitamin D from the sun. Clearly this only exacerbates the feelings that are associated with depression, such as helplessness and an overwhelmingly bleak outlook on life.

Consequences of Bulimia Nervosa

Bulimia can cause incredible damage to your health, affecting your digestive system, functioning of internal organs and overall mental health.  Your relationship with food can become an overriding obsession, wherein it becomes difficult to achieve anything in many areas of life, and difficult to even carry out normal day-to-day functions. This is not only extremely damaging to your own health, but also to your loved ones.

Of course each person’s situation varies greatly from that of another’s, but the most prominent consequences that come about from eating disorders such as bulimia include:

• Dental erosion and staining of teeth – Stomach acid is designed to stay in the stomach, however constant purging can result in stomach acid frequently splashing up the esophagus and into the mouth. Because of its acidic nature, it can cause erosion and damage to your teeth and gums.
• High risk of developing GERD–  Gastroesophageal reflux disease is a serious condition that is a result of consistent stomach acid entering the sensitive lining of the esophagus. Without treatment, this can escalate to cancer in the esophagus. Less severe conditions associated with GERD, include heartburn and acid reflux, which also adds to the risk of dental erosion.
• Poor central nervous system (CNS) -Your nervous system is important when it comes to managing stress. This is the center of control for both your body, and more importantly, your mind. Every emotion that you experience, first passes through your CNS, including thought, memory and speech. Stress invokes the release of cortisol and can affect how your CNS functions and responds to situations. This can lead to serious physical complications such as heart disease and respiratory disease. It can also increase feelings of helplessness and anxiety.
• Weakened immune system– Continually placing your body under stress and creating inflammation through consistent vomiting and a diet high in refined foods leaves you open to an array of unwanted illnesses. Emerging studies are showing that almost all diseases are borne out of an inflammatory environment, including heart disease, cancer, and rheumatoid arthritis. Stress also adds to inflammation in the body, and often bulimics struggle to face reality, as they are constantly battling their demons. Because the gut also houses 80% of your entire immune system, constant aggravation of the gut greatly affects the balance of good and bad bacteria. This only increases your risk of disease developing.
• Dehydration– The body needs water to function, but when your stomach is constantly being emptied through purging or using diuretic or laxative medication, without rehydration your body can become severely dehydrated. Signs of dehydration include having trouble thinking straight, quickly become fatigued, and dizziness. The main electrolytes lost during sweating, vomiting and even breathing are potassium, chloride and sodium.
• Stomach ulcers – Over time, the frequent production of stomach acid through vomiting can cause damage to the lining of the stomach and result in open sores. This can be recognized as burning stomach pain, bloating or vomiting blood.  Sometimes there may not even be any symptoms, which can lead to a life threatening condition due to the risk of infection or bleeding.  

Diagnosis of Bulimia Nervosa

There is a certain set of criteria that must be met in the diagnosis of bulimia. You can expect the following criteria to be examined by your doctor during an examination:

• Eating habits, including any large amount of food consumed in a very short time frame; and the feelings associated with eating habits, particularly feelings around control.
• The use of diet pills, enemas, laxatives or self-induced purging to prevent weight gain.
• The frequency at which these behaviors occur in any given week. Generally, they will need to carry out this behavior at least twice a week for three months to meet the criteria for a diagnosis of bulimia.

Physical evaluation

A full physical evaluation must take place, including the observation of symptoms commonly related to bulimia, such as hair loss, stained teeth, or tenderness in the abdominal region from the presence of stomach ulcers. Low body weight is often associated with bulimia, but is not always the case. Your doctor will take your blood pressure, test your blood and/or take urine samples to recognize any chemical imbalances or nutritional deficiencies.

Psychiatric evaluation

Because mental state is also incredibly relative to the diagnosis of bulimia, your doctor will likely refer you to a specialist psychologist who is trained in the area of eating disorders. In any event, medical professionals still need to rely on honesty from the patient in order to successfully diagnose bulimia. This is an ongoing challenge and often leads to misdiagnosis due to the feelings of shame associated with this eating disorder.

Treatment of Bulimia Nervosa

With treatment plans, there will often be a combination of medicated approaches, and what’s called cognitive-behavior therapy. Of course the type of approach your doctor will take is determined by the severity of the condition and how long the condition has been present. Responses to each type of therapy can be dependent on a variety of factors such as pre-existing mental conditions and particular personality types. Someone that has OCD or is a perfectionist might struggle with specific treatment plans.

Antidepressants

Antidepressant medications work by increasing levels of neurotransmitters such as serotonin and dopamine, which are known to increase mood. As bulimia is often borne out of feelings of depression and anxiety, taking antidepressants may help to break the destructive binge-purge cycle, by controlling thought patterns, and reducing the urge to engage in such behavior.

The most common antidepressant prescribed for bulimia is Fluoxetine, which contains serotonin, a hormone responsible for mood regulation, controlling emotions and in particular appetite. Many bulimics are found to have low levels of serotonin, which has been shown in studies to lower mood and increase irritability and even aggression. It’s interesting to also note that low serotonin ignites impulse control disorders.

Cognitive behavior therapy (CBT)

Some people struggle to open up to complete strangers and discuss issues which are incredibly personal, such as eating disorders. However, others find this much easier to do than to open up to those that are close to them. Psychologists can help manage your eating disorder and bring you back on track to good health.

CBT helps to break down your destructive thought patterns and also assists in recognizing the link between thought, mood, and action. You will work closely with a therapist that is specially trained in assisting patients with eating disorders and will help you to understand your condition. You will be provided with tools to:

• Improve your feelings of self-worth and self-judgement.
• Eliminate negative thought patterns and behaviors and replace with a healthier mindset.
• Help to identify the reality of situations, rather than the overthinking of certain situations and drawing incorrect conclusions or judgements.
• Assist with a dieting plan, focusing on high nutritional food options.
• A strong focus on resolving issues surrounding body-image and perceived beliefs.

Often programs will run from between five to twenty weeks and are specifically structured to slowly break down your challenges and obstacles that you’ve been dealing with alone up until this point. You will also be given tasks to complete as homework following your sessions.

In studies it has been recognized that intervention by way of psychotherapy is most effective in reducing binge eating and purging, than by medication alone. The chance of relapse is reduced, as the coping tools can be used for life, whereas once medication runs out, you may feel that you’re left on your own.

Non-clinical management: Bulimia Nervosa 

While antidepressants successfully block many negative emotions, they are certainty not recommended for long-term treatment. Engaging in activities that promote feelings of wellbeing is a much more sustainable approach when it comes to dealing with overwhelming emotions.

After completing CBT, you will learn that the key to success in controlling bulimia is in blocking your thought patterns and switching off your mind, if only for a few minutes! Your psychologist might recommend activities that help to achieve a more peaceful state of mind.

Yoga

Yoga is one way that helps you restore a much needed connection with your own body. This is achieved through breath work and certain strength postures. Classes range from complete beginners right through to advanced.

Yoga encourages self-love and self-worth and certainly boosts your confidence when surpassing challenging postures that require extreme focus, balance and attention. You begin to realize just how powerful your mind is in overcoming obstacles!

Another powerful message learnt from yoga is the ability to let go. This is often experienced when you’re in postures that involve a strong release of tight muscles, and you have no choice but to surrender to the position, resulting in extreme bliss when coming out of the posture!

While yoga is an ancient practice that has been around for thousands of years in India, it’s only relatively recently that science has turned to study its many incredible benefits, particularly from a psychological point of view.

In one study, titled Yoga for Psychiatry and Mental Health: An Ancient Practice with Modern Relevance, psychological benefits of yoga are noted as:

• Reduction in stress
• Regulation of emotion
• Improved mood and well-being
• Improvement in cognitive function
• Enhanced respiratory function

It’s exciting to know that yoga is already being recommended by medical professionals as part of treatment programs of mental disorders, and certainly holds an important role in forging a healthy lifestyle following the battle with bulimia and other eating disorders.