Bulimia Nervosa – A Guide

A guide to bulimia nervosa – an eating disorder and mental illness. Symptoms, causes, diagnosis and treatment.

People with bulimia nervosa binge food or have regular episodes of overeating with a feeling of loss of control. The person then uses different methods such as vomiting or abusing laxatives to prevent weight gain. Many (but not all) people with bulimia also have anorexia nervosa. Many more women than men have bulimia. The disorder is most common in adolescent girls and young women.

Introduction
Symptoms
Causes
Diagnosing
Treatment
Complications

See also: Binge Eating

Introduction

People who have bulimia try to control their weight by binge eating and then purging the food from their body by being sick or using laxatives.

As with other eating disorders, bulimia has a number of different causes, including depression, low self-esteem and stress.

Bingeing and purging

Eating disorders are characterised by an abnormal attitude towards food that causes someone to change their eating habits and behaviour. It can be difficult to understand how an eating disorder develops.

Everyone has their own eating habits. For example, people with a food intolerance need to avoid eating certain foods to stay healthy. However, the habits of people with eating disorders are motivated by an overwhelming fear of getting fat.

People with bulimia tend to alternate between eating excessive amounts of food (bingeing), and then making themselves sick or using laxatives (purging) to maintain a chosen weight. This is usually done in secret.

People with bulimia purge themselves because they feel guilty about the binge eating, but the bingeing is a compulsive act that they feel they cannot control.

Who is affected by bulimia?

Bulimia can affect men and women, but women are 10 times more likely to develop bulimia than men. However, bulimia is becoming more common in boys and men.

Recent studies suggest that as many as 8% of women have bulimia at some stage in their life. The condition can occur at any age, but mainly affects women aged between 16 and 40 (on average, it starts around the age of 18 or 19). Bulimia can affect children, but this is extremely rare.

Symptoms of bulimia

The main symptoms of bulimia are binge eating and purging (ridding your body of food by making yourself sick or taking laxatives).

Binge eating

Binge eating is repeatedly eating vast quantities of high-calorie food, without necessarily feeling hungry or needing to eat. The urge to eat can begin as an attempt to deal with emotional problems, but can quickly become obsessive and out of control.

Binge eating is usually a very quick process and you may feel physically uncomfortable afterwards. When binge eating is a symptom of bulimia, it happens regularly, not just once or twice.

Sometimes, the binges are spontaneous, where you eat anything you can find at that moment. Binge eating episodes can also be planned, where you make a shopping trip to buy foods specifically to binge on.

Purging

Purging is a response to bingeing. After you have eaten lots of food in a short space of time, you may feel physically bloated and unattractive. You may also feel guilty, regretful and full of self-hatred.

However, the main impulse to purge is a powerful, overriding fear of putting on weight.

The most common methods of purging involve making yourself sick or using laxatives to encourage your body to pass the food quickly.

Less common methods of purging include taking diet pills, over-exercising, extreme dieting, periods of starvation or taking illegal drugs, such as amphetamines.

Cycle of guilt

Bulimia is often a vicious circle. If you have the condition, it is likely that you have very low self-esteem. You may also think you are overweight, even though you maybe at or near a normal weight for your height and build.

This may encourage you to set yourself strict rules about dieting, eating or exercising, which are very hard to maintain. If you fail to keep to these strict rules, you binge on the things that you have denied yourself. After feeling guilty about bingeing, you purge to get rid of the calories.

Other signs of bulimia

Other signs of bulimia can include:

• regular changes in weight
• an obsessive attitude towards food and eating
• large amounts of money being spent on food
• disappearing soon after eating (usually visiting the toilet to vomit)
• episodes of over-eating
• periods of starvation
• scarred knuckles (from forcing fingers down the throat to bring on vomiting)
• depression and anxiety
• unrealistic opinions about body weight and shape
• isolation

Causes of bulimia

There is no simple answer to the question of what causes bulimia. Although the condition is linked to a fear of getting fat, more complex emotions usually contribute to the problem. The act of bingeing and purging is often a way of dealing with these intense emotions.

Some common factors that may lead to bulimia are outlined below.

Low self-esteem

If you have an eating disorder, you may have a low opinion of yourself and see losing weight as a way of gaining self-worth.

Depression

You may use bingeing as a way of coping with unhappiness. People with bulimia often feel depressed, so they binge regularly. However, purging does not relieve this depression and the cycle continues.

Stress

Bulimia can sometimes occur following stressful situations or life events. For example, you may develop the condition after dealing with a traumatic experience, such as a death or divorce, or during the course of important life-changing events, such as getting married or leaving home.

Bulimia can also occur in people who have experienced physical illness, and in people who have been sexually abused. Some people with bulimia have experienced a difficult childhood, with family problems, arguments and criticism.

Other mental health problems

Bulimia is often linked with other psychological problems. Research shows that bulimia is more common in people who have anxiety disorders, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and personality disorders.

Cultural and social pressure

Some people believe that the media and fashion industry create pressure for people to aspire to low body weights.

Puberty

Many young people become affected by eating disorders around the time of puberty, when hormonal changes can make them more aware of their body.

If teenagers feel they have no say in their lives, bulimia can seem like the only way they can take control.

Genetics

There may be a genetic factor related to developing bulimia. Research suggests that people who have a close relative who has or has had bulimia are four times more likely to develop it than those who do not have a relative with the condition.

Diagnosing bulimia

If you have an eating disorder such as bulimia, the first step is to recognise that you have a problem and visit your GP.

This may be a very difficult step for you to take. Most people who have bulimia hide their situation for months or years before seeking help. It can often take a change of situation, such as the start of a new relationship or living with new people, to make a person with bulimia want to seek help.

Once you have explained your situation to your GP, they will decide whether to refer you for help from a specialist mental health team. Your local team will include specialist counsellors, psychiatrists, psychologists, nurses, dietitians and other healthcare professionals.

The course of your treatment depends on how serious your condition is and the best way to manage it. Your GP may recommend a self-help programme to start your recovery before referring you for specialist treatment.

If you think you have bulimia …

• Have the courage to admit to yourself that you have a problem. You may think it is not serious, but bulimia can damage your long-term health.
• Accepting that you need help and support is the first step to recovery.
• It may help to make a list of questions you want to ask before you see your GP.
• You can make a full recovery from bulimia. The earlier you start treatment, the quicker the recovery process will be.

Treating bulimia nervosa

You can recover from bulimia, but it may be a long and difficult process.

The first step towards getting better is to recognise the problem and to have a genuine desire to get well. This may involve a big change in lifestyle and circumstances.

Treatment usually begins with psychological treatments, aimed to help you re-establish healthy attitudes towards eating. People with bulimia need to explore and understand the underlying issues and feelings that are contributing to their eating disorder, and change their attitudes to food and weight.

Sometimes, your GP may suggest you try medication, usually in addition to psychological treatment.

Psychological treatment

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is the most common type of psychological treatment for bulimia. It involves talking to a therapist and looking at your emotions in detail to work out new ways of thinking about situations, feelings and food. It may also involve keeping a food diary, which will help determine what triggers your binge eating.

Interpersonal therapy

As with CBT, interpersonal therapy (IPT) involves meeting with a therapist to discuss your condition. However, the focus is more on your personal relationships than your problems with food.

You are more likely to be referred for this type of psychological treatment if you have recently lost a loved one and have experienced a big change in your life. The aim of IPT is to help you establish supportive relationships. This can help draw your focus away from eating.

Medication

Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may be used to treat bulimia. The SSRI usually recommended to treat bulimia is called fluxetine (brand name Prozac).

SSRIs are mainly used to treat depression, but they are also used to treat eating disorders, obsessive compulsive disorder (OCD), anxiety and social phobia.

As with any antidepressant, an SSRI will usually take several weeks before it starts to work. You will usually be started on a low dose, which is then gradually increased as your body adjusts to the medicine.

When you start taking an SSRI, see your GP after two, four, six and twelve weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

Very few drugs are recommended for children and young people below the age of 18. It is also best not to take SSRIs if you have epilepsy or a family history of heart, liver or kidney disease.

Hospital treatment

Bulimia is not usually treated in hospital. However, if you have serious health complications and your life is at risk, you may be admitted to hospital. Hospital treatment is also considered if you are at risk of suicide or self-harm.

The recovery process

Once diagnosed, people with bulimia can recover, but it may take a long time. It can be very difficult, both for the person affected and their family and friends.

To recover, someone with bulimia needs to:

• change their eating habits
• change the way they think about food
• gain weight safely, if necessary

The longer someone has had bulimia, the harder it is to re-learn healthy eating habits and gain weight. It is important to start treatment as early as possible, so the person has the best chance of recovery.

For most people, recovery goes through several stages, where progress may be involve steps forward and steps back.

Complications of bulimia

There are a number of physical complications associated with bulimia:

• dental problems. Persistent vomiting can cause your stomach acid to damage the enamel on your teeth, which may lead to tooth decay. Excessive vomiting can also cause bad breath and a sore throat
• irregular periods. Your menstrual cycle can become unpredictable, or even stop altogether. You may also find it difficult to become pregnant in the future
• poor skin and hair. A lack of nutrients through persistent vomiting or laxative use can make your skin and hair unhealthy. Your skin and hair can become dry and your fingernails can become brittle
• swollen glands. If you have bulimia, your saliva glands can become swollen from frequent vomiting. This makes your face appear rounder
• chemical imbalance. Excessive vomiting and laxative use can cause chemical imbalances in your body. This can result in tiredness, weakness, abnormal heart rhythms, kidney damage, convulsions (fits) and muscle spasms
• bowel problems. Excessive use of laxatives can damage your bowel muscles, resulting in permanent constipation
• heart problems. Long-term complications of bulimia can include an increased risk of heart problems.