Symptoms and treatment of bulimia nervosa

Are you concerned that you might be suffering from an eating disorder or another mental health condition? In this article, we will explain what bulimia nervosa is, highlight the key signs and symptoms to watch out for, and list some of the different treatment options available. We’ll also offer some advice on how to avoid binge eating and maintain healthier eating habits.

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What is bulimia nervosa?

Bulimia nervosa is an eating disorder which can be highly dangerous and in some cases life-threatening.

The first clinical paper on bulimia was published in 1979 by the British psychiatrist Dr Gerald Russell. He initially believed it was a variation of anorexia, however, through the course of his research, Russell realised that he was dealing with a very different condition. (1)

Both disorders are driven by an extreme fear of gaining weight. However, while anorexics deprive themselves of food, people with bulimia go through cycles of binge eating, followed by purging.

During a binge, people with bulimia consume large amounts of food in a short space of time. Binge eating is often accompanied by distress and the feeling of being out of control. (2)

Later, sufferers attempt to purge themselves of the excess calories to avoid gaining weight. Purging may be induced vomiting, taking laxatives or diuretics, fasting or over-exercising.

Bulimia nervosa can vary in severity. 1 to 3 cycles of binging and purging per week is classed as a mild case. Extreme cases can result in  14 or more episodes in a week.

The condition is most common in young women, although it can also occur in men. It affects 1.5% of women and 0.5% of men, and it often develops in adolescence or early adulthood. (3)

Bulimics are often of an average weight, which can make it more difficult to detect. (1)

What are the symptoms of bulimia nervosa?

Are you concerned that you or someone you know may have bulimia?

The following behaviours are all warning signs:

  • Intense worrying about weight
  • Frequent self-criticism and low self-esteem related to body image
  • An obsession with counting calories or following restrictive diets
  • Often going to the bathroom immediately after eating
  • Anxious about eating in public
  • Exercising compulsively
  • Eating unusually large amounts of food in one sitting
  • Using laxatives, diuretics, or diet pills

Bulimia nervosa can take a toll on the body and cause physical damage. Some of the physical signs to look out for are:

  • Unhealthy/dry skin, hair, nails and lips resulting from dehydration
  • Damaged teeth and gums because of the acid from vomiting
  • Irregular or halted menstruation in women (amenorrhea)
  • Swelling in the hands, feet or face
  • Calluses on the knuckles or back of hands, caused by putting hands in the mouth to induce vomiting
  • Dramatic weight loss or unstable weight
  • Fatigue or exhaustion

Left untreated, bulimia can lead to serious complications, including digestive issues, kidney failure, heart problems, damage to the esophagus, nutrient deficiencies, and electrolyte imbalances.

Eating disorders

What are eating disorders?

Eating disorders are a group of psychological disorders which are defined by an abnormal relationship to food and harmful eating habits.

Anorexia nervosa, bulimia nervosa and binge eating disorder (BED) are some common eating disorders. Many people suffer from a combination of the symptoms of all three. (4)

Less common disorders include pica, which is a craving for non-food substances, and avoidant/restrictive food intake disorder which is characterised by the avoidance of certain food groups, which can lead to malnutrition.

Because these are psychological disorders, scientists are keen to learn more about how eating disorders affect brain function.

Some research suggests that anorexics and bulimics may have altered brain structure, especially in the reward system and appetite regulation. It can be challenging for people with eating disorders to regulate their food intake and sense when they are hungry or full. (5)

What causes eating disorders?

The exact cause of eating disorders is not fully understood. Research suggests that in fact there is no one single cause. Rather, scientists have identified a number of cultural, psychological, and biological factors that can indicate a higher likelihood of developing an eating disorder.

Plenty of evidence points to some genetic disposition, however the genes do not act alone but in combination with environmental factors. (6)

The following can all be risk factors for developing an eating disorder:

History of mental illness

There is a link between eating disorders and other mental illnesses such as anxiety and depression. (7)

There are also some personality traits and disorders that are associated with a higher risk of eating disorders, such as perfectionism, low self-esteem, obsessive compulsive disorder, impulsivity, self-harm, and alcohol or drug abuse. (8) (9)

Societal pressure

It’s well established that the idealization of slimness and beauty in society increases the prevalence of eating disorders. (10)

In fact, shortly after bulimia nervosa was first included in the Diagnostic and Statistical Manual of Mental Disorders in 1980, the condition quickly spread all around the world. 

Millions of women developed the disorder, and Dr Gerald Russell, in an interview with The Cut years after his groundbreaking research, even suggested that it may have been the publicity and greater awareness of the disease that contributed to its rapid spread as a social contagion. (11)

Bullying can also have an impact. Young adolescents who are victims of bullying have a greater chance of developing an eating disorder. (12)

Family and childhood trauma

A number of studies into family dynamics revealed that having a family member with anorexia or bulimia increased a person’s chances of having the condition themselves.

This could be a combination of genetic predisposition, and a family environment that values thinness or promotes disordered eating patterns. (13)

Studies also show some correlation between past sexual abuse and eating disorders like bulimia. (14)

bulimia nervosa

The most effective treatment for bulimia nervosa

There is no simple remedy for eating disorders. Even patients who have recovered can suffer relapses and for this reason many describe it as a lifelong struggle.

However, they can be managed and eventually cured in time with a mixture of treatments.

The most successful treatments include psychotherapy, such as Cognitive Behavioural Therapy, or anti-depressants, and many approaches use a mixture of the two. (15)

If you are suffering with bulimia nervosa or another eating disorder it is crucial that you seek professional help from a doctor who will be able to work out the best treatment plan for your situation.

How to stop compulsive eating

While there is no substitute for professional treatment, there are some things you can do to improve your eating habits. The key is to make gradual, sustainable changes and aim for a balanced, healthy diet.

  • Have smaller meals frequently. Research shows that eating larger meals, less frequently, can increase blood sugar levels and the hunger-stimulating hormone ghrelin. (16)
  • Avoid highly restrictive diets and fasting. Fasting and cutting out food groups is associated with a higher risk of cravings and binge eating. (17) (18) 
  • Drink plenty of water. Increasing water intake could be linked to decreased hunger and calorie intake. (19) 
  • Eat more fiber. Fruits, vegetables, legumes, and whole grains are all fiber-rich foods. Fiber helps you feel full for longer and could help you cut cravings, reduce appetite, and therefore reduce your food intake. (20)
  • Exercise and be mindful. Studies show that exercise helps to reduce binge eating and can even improve the effectiveness of cognitive-behavioral therapy for binge eating. (21) (22) Exercise can also decrease stress, boost your mood, and make you less likely to turn to binge eating to feel better. (23)
  • Try meditating. Studies reveal that mindfulness and meditation can also help reduce binge eating. (24)
  • Improve your sleeping habits. 8 hours is the optimum amount of sleep time for most people. One study found that people who sleep less had higher levels of the hunger hormone ghrelin, and lower levels of leptin, which is the hormone that promotes fullness. (25) People who binge eat may also be more likely to suffer from insomnia. (26)
  • Remove temptation. Make it easier to stick to good habits and resist the temptation to binge by filling your fridge and cupboards with healthy snacks like fruit, nuts, and vegetables. 
  • Try meal prepping. Planning and preparing meals, and measuring out portion sizes in advance might help you avoid binging.  

Conclusion: bulimia nervosa

Eating disorders are debilitating conditions that can have a major impact on many aspects of your mental and physical wellbeing. While the causes of eating disorders are complex and still not fully understood, there are lots of effective treatment options available and they can be overcome with time.

References

(1) Russell, G. (1979). Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine, 9(3), 429-448. doi:10.1017/S0033291700031974

(2) Mathes, W. F., Brownley, K. A., Mo, X., & Bulik, C. M. (2009). The biology of binge eating. Appetite, 52(3), 545–553. https://doi.org/10.1016/j.appet.2009.03.005

(3) Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication [published correction appears in Biol Psychiatry. 2012 Jul 15;72(2):164]. Biol Psychiatry. 2007;61(3):348‐358. doi:10.1016/j.biopsych.2006.03.040

(4) Smink FR, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatry. 2013;26(6):543‐548. doi:10.1097/YCO.0b013e328365a24f

(5) Frank, G., Shott, M., Riederer, J. et al. Altered structural and effective connectivity in anorexia and bulimia nervosa in circuits that regulate energy and reward homeostasis. Transl Psychiatry 6, e932 (2016). https://doi.org/10.1038/tp.2016.199

(6) Sara E. Trace, Jessica H. Baker, Eva Peñas-Lledó, and Cynthia M. Bulik, The Genetics of Eating Disorders, Annual Review of Clinical Psychology Volume 9, 2013 Trace, pp 589-620 https://doi.org/10.1146/annurev-clinpsy-050212-185546

(7) Swinbourne JM, Touyz SW. The co-morbidity of eating disorders and anxiety disorders: a review. Eur Eat Disord Rev. 2007;15(4):253‐274. doi:10.1002/erv.784

(8) Camacho, Jaime & Escoto, Consuelo & Diaz, Juan & Franco-Paredes, Karina & Díaz-Reséndiz, Felipe. (2012). Neuropsychology of Bulimia Nervosa: New Findings. 10.5772/32866. 

(9) Harrop EN, Marlatt GA. The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment. Addict Behav. 2010;35(5):392‐398. doi:10.1016/j.addbeh.2009.12.016

(10) Culbert KM, Racine SE, Klump KL. Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry. 2015;56(11):1141‐1164. doi:10.1111/jcpp.12441

(11) Lee Daniel Kravitz: The Strange, Contagious History of Bulimia, The Cut, July 31, 2017

(12) Copeland WE, Bulik CM, Zucker N, Wolke D, Lereya ST, Costello EJ. Does childhood bullying predict eating disorder symptoms? A prospective, longitudinal analysis. Int J Eat Disord. 2015;48(8):1141‐1149. doi:10.1002/eat.22459

(13) Culbert KM, Racine SE, Klump KL. Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry. 2015;56(11):1141‐1164. doi:10.1111/jcpp.12441

(14) Welch SL, Fairburn CG. Sexual abuse and bulimia nervosa: three integrated case control comparisons. Am J Psychiatry. 1994;151(3):402‐407. doi:10.1176/ajp.151.3.402

(15) Stefini A, Salzer S, Reich G, et al. Cognitive-Behavioral and Psychodynamic Therapy in Female Adolescents With Bulimia Nervosa: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry. 2017;56(4):329‐335. doi:10.1016/j.jaac.2017.01.019

(16) Carlson, O., Martin, B., Stote, K. S., Golden, E., Maudsley, S., Najjar, S. S., Ferrucci, L., Ingram, D. K., Longo, D. L., Rumpler, W. V., Baer, D. J., Egan, J., & Mattson, M. P. (2007). Impact of reduced meal frequency without caloric restriction on glucose regulation in healthy, normal-weight middle-aged men and women. Metabolism: clinical and experimental, 56(12), 1729–1734. https://doi.org/10.1016/j.metabol.2007.07.018

(17) Stice, E., Davis, K., Miller, N. P., & Marti, C. N. (2008). Fasting increases risk for onset of binge eating and bulimic pathology: a 5-year prospective study. Journal of abnormal psychology, 117(4), 941–946. https://doi.org/10.1037/a0013644

(18) Polivy J, Coleman J, Herman CP. The effect of deprivation on food cravings and eating behavior in restrained and unrestrained eaters. Int J Eat Disord. 2005;38(4):301‐309. doi:10.1002/eat.20195

(19) Davy BM, Dennis EA, Dengo AL, Wilson KL, Davy KP. Water consumption reduces energy intake at a breakfast meal in obese older adults. J Am Diet Assoc. 2008;108(7):1236‐1239. doi:10.1016/j.jada.2008.04.013

(20) Burton-Freeman B. Dietary fiber and energy regulation. J Nutr. 2000;130(2S Suppl):272S‐275S. doi:10.1093/jn/130.2.272S

(22) Levine MD, Marcus MD, Moulton P. Exercise in the treatment of binge eating disorder. Int J Eat Disord. 1996;19(2):171‐177. doi:10.1002/(SICI)1098-108X(199603)19:2<171::AID-EAT7>3.0.CO;2-K

(23) Pendleton VR, Goodrick GK, Poston WS, Reeves RS, Foreyt JP. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord. 2002;31(2):172‐184. doi:10.1002/eat.10010

(24) Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for mental health. Primary care companion to the Journal of clinical psychiatry, 8(2), 106. https://doi.org/10.4088/pcc.v08n0208a

(25) Katterman SN, Kleinman BM, Hood MM, Nackers LM, Corsica JA. Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: a systematic review. Eat Behav. 2014;15(2):197‐204. doi:10.1016/j.eatbeh.2014.01.005

(26) Taheri, S., Lin, L., Austin, D., Young, T., & Mignot, E. (2004). Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PLoS medicine, 1(3), e62. https://doi.org/10.1371/journal.pmed.0010062

(27) Kenny TE, Van Wijk M, Singleton C, Carter JC. An examination of the relationship between binge eating disorder and insomnia symptoms. Eur Eat Disord Rev. 2018;26(3):186‐196. doi:10.1002/erv.2587

(28). Ducrot, P., Méjean, C., Aroumougame, V., Ibanez, G., Allès, B., Kesse-Guyot, E., Hercberg, S., & Péneau, S. (2017). Meal planning is associated with food variety, diet quality and body weight status in a large sample of French adults. The international journal of behavioral nutrition and physical activity, 14(1), 12. https://doi.org/10.1186/s12966-017-0461-7