What Is Bulimia Nervosa?

In the United States, there has been a culturally driven obsession with weight loss and body image.

Just look at the models and actresses we see on television, in movies, in women’s magazines, and online. Many studies have documented the impact of media on a drive to attain thinness. The pressures even begin in school-age kids.

And in our own personal conversations, what do you hear, male or female, when you’ve lost 5-10 pounds? “You look great!”

Fortunately, the impact of media studies has made most of us aware of the ill effects on women in particular, and television has done an excellent job over the last decade of exposing us to a wider range of stars with different body sizes and shapes.

In this blog post, I'll focus on Bulimia Nervosa. It had been called “the secretive syndrome” because most of the folks who suffer from this disorder are normal or slightly above weight and hide their behavior. Their shame, often personal torture, makes it very different from women with Anorexia Nervosa.

Those with anorexia nervosa, though compulsively driven to thinness, are usually extremely gratified by refraining from eating and losing weight. Their eating disorder is not viewed as foreign from their personal experience. It is not an intrusion.

This is quite the opposite in the case of bulimia nervosa. It feels like something foreign has taken over and is in the driver’s seat.

“Karen”

Let’s begin with a vignette, drawn from a number of young women I have seen over the years:

Karen was a sophomore in college. She was deeply involved in her sorority, loved to drink and party, and was a top student. She played on the school softball team. After meals, Karen would frequently leave abruptly to go to the bathroom. One time a friend happened to find her vomiting in the bathroom stall. Her friend had no clue whether to confront her or to keep it to herself. Karen would often hoard food, mostly carbohydrates, like loaves of bread, boxes of cookies or doughnuts, and frantically eat them late at night, then purge. She became clinically depressed, binged more and more frequently, increased her alcohol consumption, and had to take a medical leave of absence. No one knew exactly why she was out, other than knowing she was depressed and out of control at parties.

In my clinical practice, I have worked with many women who have had anorexia and bulimia nervosa. I have found these young women to be among the brightest, most sensitive, and caring individuals I have known. And most families are dutiful, loyal, and dedicated to the well-being of their kids.

But something goes terribly wrong.

What Is Bulimia Nervosa?

Bulimia Nervosa is a disorder that is characterized by episodes of eating a large amount of food in very short periods of time, with a feeling that there is no control of this behavior. It is an irresistible compulsion. Following binges, there is the impulse to compensate for the behavior by purging – and this might include vomiting, induced by one’s finger or taking some medication such as Ipecac, laxatives or diuretics, or going on a long run.

Binges typically occur on average once a week though sometimes multiple times a week. The purging behavior is tied to attempts to control body shape and weight.

From a psychological perspective, bulimia feels like an addiction. It feels like something the person cannot control, and often results in very low self-esteem, poor self-image, and is not a pleasant experience. It feels “disgusting” and “out of control.” – bulimia is a living torture. The intense shame often obstructs seeking help.

Associated Features

Bulimia tends to be three times more common in women than in men, and it typically begins in the late teens or early 20s.

People with bulimia nervosa often have personal characteristics that may not be severe enough to create dysfunction. These are the features we are born with. The traits often seen in folks with bulimia include perfectionism; compulsive behavior (need for control, exactness, and order); impulsivity (often associated with abrupt and, at times poor decision making); and narcissism (extreme needs for validation and admiration, self-centered behavior, excessive focus on image).

There are also a number of psychiatric disorders that are very common in people who have bulimia.

Depression is the most common associated disorder and occurs in about 50% of cases. Other common associated problems include:

• Anxiety disorders such as phobias, social anxiety, and obsessive compulsive disorder
• Posttraumatic stress disorder
• Attention deficit hyperactivity disorder
• Substance use disorder

There are a number of risk factors for bulimia including childhood trauma, such as sexual abuse, and discontinuation of psychotherapy.

Of considerable importance is that, like many other mental health disorders, multiple factors have an added impact. For bulimia nervosa, a history of childhood maltreatment is often associated with depressive conditions, anxiety disorders, and borderline personality disorder. And in these cases, the prognosis is worse.

Bulimia nervosa has also been associated with personality disorders. Many patients and family members ask about personality disorders and just what they mean. Personality disorders should not be confused with disorders of the “person.” Rather, they are labels that indicate a constellation of behavioral, emotional, and cognitive characteristics that cause problems in one’s social, occupational or academic, and recreational life. While I am not fond of the label “personality disorders,” I understand that it is shorthand for looking at a cluster of qualities that more often than not are present together.

The most common personality disorder associated with bulimia is Borderline personality disorder. Borderline traits include:

• Difficult, often stormy interpersonal relationships
• Intolerance or uncontrolled anger
• Feelings of aloneness or emptiness
• Seeing the world in black and white terms – as all good or all bad
• Difficulty regulating emotions; low self-worth
• Self-destructive behaviors such as suicide attempts, shoplifting, substance abuse, and impulsivity.

Medical Complications and Outcome

People who have bulimia nervosa often have complications that result from excessive purging, including:

• Dehydration
• Loss of salts in the blood (electrolytes)
• Gastrointestinal problems, such as inflammation of the stomach or esophagus
• Enlarged salivary glands (from eating excessive carbohydrates that stimulate saliva production)
• Erosion of dental enamel with increased risk of cavities, due to the acid in vomit

The good news about bulimia is that with treatment 30-80% have a remission. However, the recurrence rate is very high. This means that even if the symptoms abate, ongoing care and attention to the underlying problems need attention.

The bad news is that the death rate for bulimia is quite high. Now when considering mortality, most studies have looked at a composite death rate – death due to all causes – the combined effects of bulimia with other behaviors and disorders. The all-cause death rate for bulimia nervosa is 2-8 times greater than the rate for the general population. This is largely due to the increased rates of suicide.

Treatment

Treatment for bulimia nervosa can be highly effective.

It generally involves a team effort, including a primary care physician, nutritionist, and mental health clinicians.

The most important treatments include monitoring of medical and nutritional status, including possible medical complications and psychiatric care.

From the mental health standpoint, effective treatments include psychotherapy, most importantly, cognitive behavior therapy. Additional psychotherapy methods for many patients include mindful meditation, techniques to regulate emotions, and family therapy. Medications, and in particular the antidepressant medications are extremely valuable in diminishing binging and purging episodes. They also treat associated depression, anxiety, and obsessive compulsive disorders if present, and diminish impulsivity. The selective serotonin reuptake inhibitors (SSRIs) are among the most effective antidepressant for bulimia nervosa.

Prevention

I cannot emphasize enough the value of prevention for eating disorders. Among the most important preventative measures are: increasing knowledge of the illness, and using techniques to reduce the importance of body image and thinness for our kids – starting this as early as possible, both at home and in school. Studies have also found that programs that can diminish the need for dieting and increase the emphasis on good nutrition and healthy eating patterns, without need for dieting, and improving emotional regulation all help.

Prevention is most effective for bulimia nervosa (and virtually all other mental health problems) if programs are conducted in all areas in which the child lives – at home, in school, in after school and community programs.

Now let’s go back to Karen:

I began seeing Karen on her medical leave from college. For the initial phase of our work, she was very reluctant to talk with me about the details of her binging and purging, and avoided talking about her body image. In time I earned her trust and we began discussing details of her impulses to binge and purge. My goal was to increase the interval from the impulse to binge to the action. The longer I could help her increase this interval the less powerful the impulse led to binging and purging.

What helped? Medication. Meditation. Use of humor. Appreciation of what we liked in pop culture, including music, films, and other media. Looking at photos of women together and candidly talking about how she compared herself to them. And discussing the exaggerated or distorted thoughts (cognitions) she had about her body, self, and relationship with others.

This progressed to discussing her use of alcohol, and her sexual behavior in order to achieve positive self-esteem. We then considered other means of feeling good about herself. We also talked about ways of controlling her emotions. I brought in her family to help them understand her disorder and help out when she needed it. We also talked about her remote history of sexual abuse from another kid in the neighborhood, and its shameful and devastating impact on her. This was new news to her parents.

In three or four months her binging stopped. There were recurrences, but we did not let them derail us from our work. I stayed in touch with her and have been working with her for over 10 years following her return to school.

Young people like Karen need an anchor in their lives, one who, despite the ups and downs of these long term problems, will not give up on them, and one who becomes a trusted friend.

As I say to all my eating disorder patients – this is a marathon, not a sprint.

And then, we work hard together and hope for the best.

That is about the best we can do, but it is worth doing every single time.

As we recognize National Eating Disorder Awareness Week, I hope the information I share above will be both informative and useful. For even more information about eating disorders, and ways you can help make a difference in the life of a loved one or for yourself, please visit the National Eating Disorder Association or the Psychology Today Therapy Directory.

A version of this blog was posted on The Clay Center for Young Healthy Minds at the Massachusetts General Hospital.