Bulimia Nervosa

What is bulimia?

Bulimia nervosa is characterized by frequent episodes of binge eating, from twice a week to multiple times a day, followed by frantic efforts to avoid gaining weight.

During an average binge, a bulimic consumes 3,000 to 5,000 calories in one short hour. After it ends, the person turns to drastic measures to “undo” the binge, such as taking ex-lax, inducing vomiting, or going for a ten-mile run.

The key features of bulimia nervosa are:

• Regular episodes of out-of-control binge eating
• Inappropriate behavior to prevent weight gain
• Self-worth is excessively influenced by weight and physical appearance

There are two types of bulimia, distinguished by the methods the bulimic uses to compensate for the binge eating. In the purging type of bulimia, people physically purge the food from the body by throwing up or using laxatives, enemas, or diuretics. In the nonpurging type of bulimia—which is much less common—bulimics make up for their lack of restraint by fasting, exercising to excess, or going on crash diets.

Women are much more likely than men to develop bulimia; approximately 90% of those with the disorder are female. Younger women are particularly at risk. Bulimia typically begins during the late teens or early twenties, often following a strict period of dieting or a stressful life event.

DO I HAVE BULIMIA?
Ask yourself the following questions. The more “yes” answers, the more likely you’re suffering from bulimia or another eating disorder.
Are you obsessed with your body and your weight? Does food and dieting dominate your life? Are you afraid that when you start eating, you won’t be able to stop? Do you ever eat until you feel sick? Do you feel guilty, ashamed, or depressed after you eat? Do you vomit or take laxatives to control your weight?

The binge and purge cycle

Bulimia’s destructive cycle of bingeing and purging is triggered by dieting. Driven by a desire to be thin, people with bulimia go on strict diets. But the more rigid and restrictive the diet plan, the more preoccupied they become with food. They obsess over what, when, and how much to eat, what they shouldn’t eat, and how to avoid eating. At the same time, their calorie restriction triggers physical cravings—the body’s way of asking for the nutrition it needs.

As the tension, hunger, and feelings of deprivation build, the compulsion to eat becomes too powerful to resist: a “forbidden” food is eaten; a dietary rule is broken. In the all-or-nothing mindset of bulimics, any slip-up is a total failure. They’ve already blown it, so they might as well let go and enjoy an all-out binge. But the enjoyment of a bingeing is soon replaced with feelings of guilt, revulsion, and self-loathing.

In an effort to regain control and make up for the excess calories eaten, most bulimics purge to make up for their bingeing. While purging is intended to counteract binge eating, it ends up reinforcing it. It’s harder to say no to temptation when you think you can avoid the consequences. “This is the last time,” people with bulimia tell themselves as they launch into a new diet. In the back of their minds, however, they know that they can always throw up, pop a water pill, or use laxatives if they lose control again. What they don’t realize is that purging doesn’t come close to wiping the slate clean after a binge.

Signs and symptoms of bulimia

People who have bulimia usually try to hide their bingeing and purging. They’re ashamed over their inability to control themselves, so they binge when others aren’t around. If they clean out the fridge, they’ll replace the food so others in the house won’t notice how much they’ve eaten. If they’re buying food for a binge, they’ll go to four separate markets so the checker won’t suspect what they’re up to. They’ll gorge late at night or behind locked doors—anything to conceal their eating habits. But despite the secrecy, there are warning signs and symptoms of bulimia that can alert you to the problem.

Despite the fear bulimics have of becoming fat, being underweight is not a characteristic warning sign of bulimia. In fact, people with bulimia are usually of normal weight or are even overweight. If a person binges and purges but is dramatically underweight, he or she most likely suffers from the purging type of anorexia, rather than bulimia.

Binge eating signs and symptoms

• Lack of control over eating. Inability to stop eating. Eating until the point of physical discomfort and pain.
• Secrecy surrounding eating. Going to the kitchen after everyone else has gone to bed. Going out alone on unexpected food runs. Wanting to eat in privacy.
• Eating unusually large amounts of food with no obvious change in weight.
• Disappearance of food, numerous empty wrappers or food containers in the garbage, or hidden stashes of junk food.
• Alternating between overeating and fasting. Rarely eats normal meals. It’s all-or-nothing when it comes to eating.

Purging signs and symptoms

• Going to the bathroom after meals – Frequently disappears after meals or takes a trip to the bathroom to throw up. May run the water to disguise sounds of vomiting.
• Using laxatives, diuretics, or enemas after eating. May also take diet pills to curb appetite or use the sauna to “sweat out” water weight.
• Smell of vomit. The bathroom or the person may smell like vomit. They may try to cover up the smell with mouthwash, perfume, air freshener, gum, or mints.
• Excessive exercising – Works out strenuously, especially after eating. Typical activities include high-intensity calorie burners such as running or aerobics.

Physical signs and symptoms of bulimia

• Calluses or scars on the knuckles or hands from sticking fingers down the throat to induce vomiting.
• Puffy “chipmunk” cheeks caused by repeated vomiting.
• Discolored teeth from exposure to stomach acid when throwing up. May look yellow, ragged, or clear.
• Frequent fluctuations in weight - Weight may fluctuate by 10 pounds or more due to alternating episodes of bingeing and purging.

Effects of bulimia

Chronic bingeing and purging leads to many health problems—some of them life-threatening. The most dangerous side effect of bulimia is dehydration due to purging. Vomiting, laxatives, and diuretics can cause electrolyte imbalances in the body, most commonly in the form of low potassium levels. Low potassium levels trigger a wide range of symptoms ranging from lethargy and cloudy thinking to irregular heartbeat and death. Chronically-low levels of potassium can also result in kidney failure.

Other common medical complications and adverse effects of bulimia include:

Weight gain Abdominal pain, bloating Swelling of the hands and feet Chronic sore throat, hoarseness Broken blood vessels in the eyes Swollen cheeks and salivary glands

Weakness and dizziness Tooth decay and mouth sores Acid reflux or ulcers Ruptured stomach or esophagus Loss of menstrual periods Chronic constipation from laxative abuse

The dangers of ipecac syrup

Regular use of ipecac syrup, a medicine used to induce vomiting, can be deadly. Ipecac is particularly dangerous because it builds up in the body over time. Eventually, it can damage the heart and lead to sudden cardiac arrest, as in the case of singer Karen Carpenter, whose early death was attributed to ipecac abuse.

Source: National Women's Health Information Center

Bulimia causes and risk factors

There is no single cause of bulimia. While low self-esteem and concerns about weight and body image play major roles, there are many other contributing causes, including social, psychological, and biological factors.

Major causes and risk factors for bulimia include:

• Poor body image – Our culture’s emphasis on thinness and beauty can lead to body dissatisfaction, particularly in young women bombarded with media images of an unrealistic physical ideal.
• Low self-esteem – People who think of themselves as useless, worthless, and unattractive are at risk for bulimia. Things that can contribute to low self-esteem include depression, perfectionism, childhood abuse, and a critical home environment.
• Dieting – People who diet are much more likely to develop an eating disorder than those who don’t. The deprivation of drastic dieting can trigger binge eating, leading to bulimia’s binge-and-purge cycle.
• Appearance-oriented professions or activities – People who face tremendous pressure to look a certain way or stay thin are vulnerable to developing an eating disorder. Those at risk include ballet dancers, models, gymnasts, wrestlers, runners, and actors.
• Major life changes – Bulimia is often triggered by stressful changes or transitions, such as the physical changes of puberty, going away to college, or the breakup of a relationship. Bingeing and purging may be a misguided attempt to cope with the stress.
• Biological factors – Eating disorders run in families, indicating a genetic component. Research also shows that low levels of serotonin play a role in bulimia.

Bulimia treatment and recovery

Regardless of how long you’ve had bulimia, you can get better. With treatment and support, many bulimics experience a full and successful recovery. To stop the cycle of bingeing and purging, it’s important to seek professional help early, follow through with treatment, and resolve the underlying emotional issues that caused the bulimia in the first place. While recovering from an eating disorder isn’t easy, regaining your health and happiness is worth the effort.

Therapy for bulimia

Because poor body image and low self-esteem underlie bulimia, psychotherapy is an important aspect of treatment. Many people with bulimia feel isolated and shamed by their bingeing and purging, and therapists can help with these feelings.

The treatment of choice for bulimia is cognitive-behavioral therapy. Cognitive-behavioral therapy targets the unhealthy eating behaviors of bulimia and the unrealistic, negative thoughts that fuel them. Cognitive-behavioral therapy for bulimia involves two phases:

• Breaking the binge-and-purge cycle – The first phase of bulimia treatment focuses on stopping the vicious cycle of bingeing and purging and restoring normal eating patterns. Patients learn to monitor their eating habits, avoid situations that trigger a desire to binge, cope with stress in ways that don’t involve food, eat regularly to reduce food cravings, and fight the urge to purge.
• Changing unhealthy thoughts and patterns – The second phase of bulimia treatment focuses on identifying and changing dysfunctional beliefs about weight, dieting, and body shape. Patients challenge their “all-or-nothing” attitudes about eating, explore the connection between emotions and eating, and rethink the idea that self-worth is based on weight.

In addition to cognitive-behavioral therapy, there are several other bulimia treatments that are effective. Interpersonal psychotherapy helps people with bulimia solve relationship issues and interpersonal problems that are contributing to their eating disorder. Interpersonal psychotherapy also treats the depression and low self-esteem that goes along with bulimia. Group therapy is also helpful in bulimia treatment. Group therapy for bulimia involves education about the eating disorder and strategies for overcoming it. It can also help bulimics feel less alone in their suffering.

Antidepressant medications for bulimia

Antidepressants are often used in the treatment of bulimia. When combined with therapy, antidepressant medications can help reduce binge eating. They can also improve preoccupation with weight and body image, as well as the depression that often accompanies bulimia.

Helping a person with bulimia

If you suspect that your friend or family member has bulimia, talk to the person about your concerns. Your loved one may deny bingeing and purging, but there’s a chance that he or she will welcome the opportunity to open up about the struggle. Either way, bulimia should never be ignored. The person’s physical and emotional health is at stake.

Support from friends and family can really help people recover, even when they’re receiving professional help and advice.

Related links for bulimia nervosa

Signs and symptoms of bulimia

Bulimia Nervosa – Reference article on the signs, symptoms, causes, and treatment of bulimia. Includes information on complementary and alternative therapies. (University of Maryland Medical Center)

Eating Disorders: Anorexia and Bulimia – An easy-to-understand article, written for teens. Discusses symptoms, causes, effects, and treatment. (TeensHealth)

Bulimia Nervosa – Covers the self-esteem and emotional issues underlying bulimia, as well as the signs, symptoms, and diagnostic criteria. (The Something Fishy Website on Eating Disorders)

Effects of bulimia

Medical Symptoms and Complications Associated with Bulimia – Excerpt from the book The Parent's Guide to Eating Disorders covers the effects and medical complications of bulimia. (Gurze Books)

Eating Concerns and Oral Health – Covers the effects of bulimia and vomiting on the teeth, mouth, and gums. (National Eating Disorders Association)

Health Problems Resulting from Eating Disorders – Overview of the effects of bulimia, severe dieting. purging, and laxative use. (Somerset and Wessex Eating Disorders Association)

Vomiting and Your Health (PDF) – Fact sheet on the dangers of chronic vomiting. Includes myths about self-induced vomiting. (Centre for Clinical Interventions)

Laxatives and Enemas: Not the Way to Go – Learn about the effects of laxative and enema use. Includes tips for breaking the laxative habit. (Anorexia Nervosa and Related Eating Disorders, Inc.)

Bulimia causes and risk factors

Causes of Eating Disorders – Describes the causes of bulimia and other eating disorders, including negative family influences, genetic factors, and cultural pressures. (University of Maryland Medical Center)

Bulimia treatment and recovery

Promising Treatments for Anorexia and Bulimia – Article from Monitor on Psychology on effectie treatments for bulimia and anorexia. (American Psychological Association)

Eating Disorders Survival Guide – In-depth guide to negotiating with your health insurance company for your bulimia treatment, finding effective care, and covering the cost of treatment. (National Eating Disorders Association)

Bulimia Nervosa Resource Guide – Provides information on treatment options for bulimia, maximizing health insurance benefits for bulimia, and finding a treatment center. (ECRI Institute)

Finding bulimia treatment providers

Eating Disorder Treatment Finder – Searchable directory of eating disorder treatment providers, including doctors, therapists, dieticians, and support groups. (The Something Fishy Website on Eating Disorders)

EDReferral.com – Comprehensive, easy-to-search database of eating disorder and bulimia treatment providers. (The Eating Disorder Referral and Information Center)

Suzanne Barston, Melinda Smith, M.A., and Jeanne Segal, Ph.D., contributed to this article. Last modified on: 3/3/08.