Bulimia
What Is It?
Bulimia is an Eating Behavior Disorder characterized by recurrent episodes of compulsive eating. These episodes involve consuming a clearly larger amount of food in a short period of time (for example, up to two hours) than most people would eat in the same circumstances.
There is a tendency to consume highly caloric, low-nutritional-quality foods, such as sweets, cookies, and potato chips. Quickly, there is a sense of loss of control over the act of eating, with a feeling of inability to stop eating or control the quantity and quality of the food. After these episodes, feelings of guilt, ineffectiveness, low self-esteem, and distress may arise. These episodes are usually done in secret, with individuals with bulimia often taking food to safe places where they know they won't be discovered (e.g., to their room).
In the initial stages of the disorder, as a way to control weight and prevent weight gain, inappropriate and recurrent compensatory behaviors are adopted. These behaviors include inducing vomiting, using laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise. These behaviors occur, on average, at least twice a week for three consecutive months. These behaviors, initially used to combat binge eating, later take on a repetitive character. By providing relief from physical discomfort and reducing the fear of gaining weight, a vicious cycle is created: eating until full, engaging in compensatory behaviors, and so on.
What Types Exist?
Contrary to what one might think, Bulimia does not always involve vomiting after compulsive eating; between 10 and 20% of individuals with bulimia use other compensatory methods. The characterization of this disorder is based on the type of compensatory methods used:
Purging Type: in which the person regularly induces vomiting or abuses laxatives, diuretics, or enemas;
Non-Purging Type: in which the person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise.
What Are the Main Signs and Symptoms?
Bulimia is a complex condition that can be difficult to identify. It is a quieter disorder than Anorexia since it is not associated with significant weight loss or weight gain and can go unnoticed for a long time by family and friends. The fact that individuals with Bulimia appear to be in good health can mask this disorder. Therefore, it is essential to pay attention to signs in different domains:
Physical Domain:
- Headaches;
- Fatigue;
- Abdominal pains;
- Muscle weakness;
- Recurrent vomiting;
- Heartburn;
- Constipation;
- Irregular menstrual cycles;
- Irritated throat and swollen glands as a result of vomiting;
- Calluses and wounds on the hands due to induced vomiting;
- Dental problems (reduced tooth enamel/tooth decay).
2) Behavioral and Cognitive Domain:
- Obsession with diets;
- Frequent thoughts about food;
- Severe self-criticism;
- Social isolation due to avoiding restaurants, family meals, and social gatherings;
- Impulse control and self-control difficulties.
3) Emotional Domain:
- Emotional dysregulation;
- Mood swings;
- Feelings of guilt after eating;
- Self-esteem determined by weight.
What Are the Possible Causes and Risk Factors?
Psychological Factors: concern about weight, associated with the internalization of an ideal of thin body image; low self-esteem; depressive symptoms; Anxiety Disorder, especially social anxiety.
Environmental and Biological Factors: physical or sexual abuse during childhood; genetic vulnerabilities; obesity during childhood.
Can It Be Associated with Other Disorders?
Most individuals with Bulimia Nervosa tend to have other psychological disorders, including Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder. Comorbidity with alcohol and stimulant substance use disorders is quite common, affecting at least 30% of people with Bulimia Nervosa. The use of stimulants typically begins to control appetite and weight. A substantial percentage of individuals with bulimia also exhibit personality traits that meet the criteria for a Personality Disorder diagnosis, particularly Borderline Personality Disorder.
What Is the Prevalence and Mortality?
The onset of Bulimia is more prevalent from mid-adolescence to early adulthood, later than Anorexia Nervosa. During this phase of life, when identity is being structured and autonomy is consolidated, there is often difficulty in dealing with the feelings and expectations that these processes require.
Although the prevalence of Bulimia Nervosa is higher in economically developed countries, the prevalence has gradually increased in low and middle socio-economic status countries.
The risk of suicide is high in Bulimia Nervosa, with approximately one-quarter to one-third of individuals with this disorder experiencing suicidal ideation or previous suicide attempts.
How Can Psychotherapy Help?
A multidisciplinary approach is most appropriate in the treatment of Bulimia Nervosa. Nutritional counseling should be provided by a nutritionist or dietitian to correct eating errors and establish a regular meal pattern. The correction or stabilization of physical consequences should be guided by a medical professional. Psychological treatment should be conducted by a psychologist working as part of a team with other specialists.
The primary goal of psychological treatment is to end the cycle of compulsive eating followed by purging or prolonged fasting. Subsequently, it is important to identify and modify thoughts and beliefs and work on emotional regulation that trigger and perpetuate the bulimic cycle. Relaxation and emotional self-regulation techniques are frequently used, including Mindfulness, Eye Movement Desensitization and Reprocessing (EMDR), Dialectical Behavior Therapy, among others.
Family, romantic, and peer relationships are an important dimension in the context of this disorder due to the relational influence in the maintenance and expression of symptoms. Thus, this aspect can also be the focus of therapeutic attention (individual or family therapy).
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association.
Cooper, Z., & Fairburn, C. G. (2010). Cognitive Behavior Therapy for Bulimia Nervosa. The Treatment of Eating Disorders: A Clinical Handbook, 243-270.
Morins M., Fonseca S., Mendes A., Ribeiro J., Silva L. & Cruz M. (2006). 'Binge Eating' - A Case Report. Revista Comportamento Alimentar, Vol 3, nº9, pp: 9-12.
Van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2021 Nov 1;34(6):515-524.