Bulimia Nervosa: What It Is, Symptoms & Treatments

Bulimia nervosa, commonly known as bulimia, is an eating disorder that can have serious life consequences if left untreated. It is characterised by three key features: binge eating, compensatory behaviours, and self-evaluation. 

Binge eating 

Binge eating is the uncontrollable consumption of unusually large quantities of food in a short period. For someone with bulimia nervosa, these episodes are recurrent.

Compensatory behaviours

Usually, people with bulimia nervosa feel guilty after an episode of binge eating. So, as a compensatory mechanism, they engage in inappropriate behaviours to prevent weight gain, known as purging. Purging includes using laxatives (without supervision) or making themselves vomit on purpose (inducing vomiting). Some people may also do extreme exercises or fast for prolonged periods.

Self-evaluation

Most people with bulimia nervosa have a normal body weight but still make harsh judgements about their body image and shape. They also tend to have low self-esteem in their body appearance.

How common is Bulimia Nervosa?

Prevalence

On average, the age of onset of bulimia nervosa is 18 years old. It can affect any gender, but statistically speaking, women are almost five times more likely to develop bulimia than men. The prevalence of bulimia is 1.5% and 0.5% in women and men, respectively. A possible reason behind this is more societal pressure faced by women to have the “ideal” body.

In the USA, it has been noted that around 3% of the population suffer from bulimia nervosa in their lifetime, and it is more common among adolescents and young adults. A recent study also showed that the mortality rate for bulimia was 3.9%.

In India, it was found that approximately 0.4% of North Indians had bulimia nervosa. It was also noted that the prevalence of bulimia was higher in the east and north zones. The west and south zones had low prevalence, with the south being the lowest. 

Factors affecting prevalence 

No single reason can be fully attributed to the development of bulimia nervosa. It can range from one's genetic makeup and family dynamics to societal pressure and environmental influence. These will be discussed in detail in the next section.

What Causes Bulimia Nervosa?

Biological Factors 

Eating disorders like bulimia can run in families, which means having a close relative or sibling with a history of eating disorders can put one at a higher risk of developing them. According to a review (2019), a deficiency of serotonin, a neurotransmitter mainly associated with mood regulation and appetite, may be associated with the development of bulimia nervosa.

Psychological Factors 

Bullying or weight-shaming can impact one's self-esteem, especially in school-going children and adolescents. This happens because most of us want to achieve the “perfect” or “ideal” body, which can cause us to be dissatisfied with ourselves. Low self-esteem can, in turn, lead to negative body image, which paves the road to eating disorders such as bulimia nervosa.

Environmental Factors

Social and cultural factors play a key role in influencing one's body image. 

In a study conducted among ninth-grade students, the adolescents were asked what, according to them, was “healthy weight.” It was observed that most of them, especially female students, had unrealistic expectations of weight and physical appearance. Both males and females had low self-esteem due to the societal stigma attached to being overweight.

This portrays the extent of pressure exerted on youth through cultural practices, including social media, regarding body image and how much it shapes their idea of a perfect body. 

Other factors, such as emotional and physical abuse paired with food deprivation, unstable family dynamics, stressful events like breakups, and moving to new places can also influence the development of bulimia nervosa.

How Do You Know If You or someone you know Has Bulimia Nervosa?

Here are some of the symptoms and warning signs of bulimia nervosa to look out for. However, keep in mind that spotting bulimia in others can be difficult, as people with bulimia often binge eat and purge privately. 

Symptoms and Warning Signs of Bulimia Nervosa 

Behavioural and emotional symptoms of Bulimia Nervosa:

1. Constant fear and worry about gaining weight 
2. Feeling guilty about having food 
3. Preoccupied with body image; negative thoughts 
4. Eating large amounts of food in one sitting 
5. Uncontrollable urge to eat more 
6. Strict diet or fasting after an episode of binge eating
7. Excessive amounts of exercise 
8. Refusing to eat in front of others or in public
9. Frequent bathroom visits after or in between meals for long hours 
10. Withdrawing from family and other social events

Physical symptoms of Bulimia Nervosa:

1. Scars, cuts, or calluses on top of knuckles are also known as Russell's sign. This is a sign of induced or forced vomiting.
2. Swollen cheeks and jaws, known as chipmunk cheeks
3. Irregular menstrual cycles 
4. Gastrointestinal problems such as acid reflux, difficulty in passing stools
5. Muscle weakness 
6. Damaged teeth and gums
7. Fainting 
8. Constant fluctuations in weight 

Other Signs:

Finding empty food wrappers and packaging of laxative medicines (laxative abuse) can also be warning signs of bulimia nervosa.

Binge Eating Patterns: Characteristics of binge eating episodes

The binge-eating episode involves:

1. Eating portions that are larger than what people usually eat
2. Usually eats within 2 hours
3. Lacks portion control, no matter how full they may feel. They might even experience physical pain as a result of this 
4. Hoards or hides a lot of food items

Purging Behaviors: Methods used to compensate for binge eating

Purging behaviours involve recurrent, inappropriate methods to expel the food consumed during the binge episode and prevent weight gain.

1. Misuse of laxatives or enemas (to expel stools) and/or diuretics ( to urinate) 
2. Induced or forced vomiting
3. Fasting for long hours
4. Excessively working out or exercising 

Psychological Impact: Emotional distress associated with Bulimia Nervosa 

People with eating disorders such as bulimia nervosa tend to keep them a secret due to the burden of societal stigma. This can be emotionally distressing to them. After all, eating disorders are serious mental health conditions and can be mentally draining.

They may experience 

• Feelings of shame and guilt, especially after binge eating or purging 
• Sensitivity to comments about eating, body image, exercise, and dieting

How to Treat Bulimia Nervosa?

Living with bulimia nervosa can be of great concern, but remember that it is a treatable disorder with many options — therapy, medications, nutritional counselling, and support groups. 

A.Therapy for Bulimia Nervosa

The different methods of therapy include:

• Cognitive Behavioural Therapy (CBT): helps individuals with bulimia replace negative and unhealthy thoughts around food with healthy eating patterns and positive beliefs and behaviours.
• Dialectical Behavioural Therapy (DBT) helps individuals tolerate stress better, be more mindful and attain an emotional balance.
• Interpersonal Behavioural Therapy (IPT): this mode of therapy focuses on the present issues faced by the person, such as interpersonal conflicts and areas where the person is isolating themselves during the period of sickness, and helps them build and foster better social relationships.
• Maudsley Family Therapy: a family-based therapy initially developed for people with anorexia nervosa is now also used in the treatment of bulimia nervosa due to improved outcomes.

B. Medications for Bulimia Nervosa

The major category of medicines used in the treatment of bulimia nervosa is antidepressants, mainly SSRIs. 

Selective Serotonin Reuptake Inhibitors (SSRIs) don't exactly treat the symptoms of bulimia nervosa but may help reduce the frequency of binge eating and purging (vomiting).

They mostly help with associated conditions such as depression and anxiety.

Medications, when coupled with therapy, are more effective in dealing with the symptoms.

C. Nutritional Counseling for Bulimia Nervosa

Involves nutritional guidance from a dietician who has specialized training in treating people with eating disorders. They can help manage cravings and hunger pangs and assist in developing a healthier approach to food and formulate nutritious meal plans.

D. Support groups for Bulimia Nervosa

Connecting with individuals or families going through the same situation can help you feel less alone. Support groups are best when coupled with other methods of treatment, as mentioned above.

E. Hospitalization 

In some cases of bulimia, hospitalization may be required for treating complications such as electrolyte imbalance and organ damage.

Improving the efficacy of treatment includes a collaborative approach between your doctor, family, and friends and a combination of the different treatment methods.

What are the effects of Bulimia Nervosa?

In bulimia nervosa, binge eating and purging cycles can take a toll not only on one’s mental health but also physical health, and have serious short-term as well as long-term effects.

Short-term Effects of Bulimia Nervosa

1. Dental caries/ cavities
2. Swollen cheeks and jaws
3. Sore throat
4. Severe dehydration 
5. Electrolyte imbalance 
6. Dizziness 
7. Fatigue 
8. Acid reflux 
9. Stomach pain 
10. Bloating
11. Sleep disturbances 

If left untreated, these can progress into severe long-term health complications in different body systems.

Long-term Effects of Bulimia Nervosa

Dental system 

1. Enamel erosion of teeth due to continuous contact with stomach acids (acid reflux).
2. Rough or raspy voice (acid irritation to the voice box)
3. Continuous, irritable coughing due to irritation by stomach acids 
4. Increased teeth sensitivity 
5. Damage to salivary glands 
6. Loss of teeth 

Gastrointestinal system 

1. Stomach and intestinal ulcers 
2. Chronic acid reflux 
3. Tears in oesophagus (food pipe); blood in vomit can be an indicator 
4. Risk of haemorrhoids (commonly called piles) due to laxative abuse 
5. Constipation
6. Rectal prolapse (intestine slips out of the anus)
7. Increased risk of oesophageal cancer 

Heart 

1. Low blood pressure 
2. Palpitations
3. Cardiac arrhythmia (abnormal heart rhythm) 
4. Cardiac arrest

Kidney 

1. Increased chance of kidney failure due to several electrolyte imbalances 
2. Risk of kidney stones 

Bones

1. Brittle bones
2. Low bone density 
3. Increased risk of osteoporosis 

Hormones and Reproductive system 

1. Absent periods (amenorrhoea)
2. Fertility issues (both males and females)
3. In the case of pregnant women with bulimia, there is a high risk of developing complications such as miscarriage, birth defects and premature birth.

Hair and skin 

1. Dry, scaly and rough skin (due to dehydration)
2. Brittle hair and nails 
3. Hair fall

Mental Health Implications 

For some, bulimia nervosa might lead to or aggravate the following conditions :

1. Depression
2. Anxiety 
3. Obsessive-compulsive personality Disorder (OCPDs)
4. Self-harm and suicidal thoughts 

Social and interpersonal impact: relationship difficulties and isolation

Individuals with bulimia nervosa can find it difficult to navigate social and personal relationships. 

Especially when it comes to romantic relationships, things can take a tough turn. Due to preoccupied thoughts of food and body image, your partner might feel emotionally disconnected. You might even find it difficult to open up to your partner because of fear of rejection and judgment.

Another possible issue is a lack of sexual intimacy due to low self-esteem and a distorted body image. One may also experience reduced sexual drive due to a lack of proper nutrition and long hours of fasting.

How is Bulimia Nervosa Diagnosed?

To diagnose bulimia nervosa, your healthcare provider may ask whether you have or do the following:

• Does your body shape or weight have a strong influence on how you feel?  Do you often worry about it?
• Do you engage in eating episodes involving unusually large quantities of food? Do you feel out of control while doing so?
• Do you stock up on a lot of food and consume it secretly?
• Do you take any weight loss products?
• Do you exercise? If yes, how often?
• Do you engage in other activities to lose weight?
• Have any of your family members been diagnosed with an eating disorder?

The binge eating episodes should be there at least once a week for three consecutive months to qualify for a diagnosis. The more episodes there are, the more severe the bulimia is.

Along with this, the healthcare provider will conduct a thorough physical examination and may write a few lab tests to rule out any other medical conditions:

• Blood test
• Urine analysis 
• ECG
• Organ function test

Who Will Treat Bulimia Nervosa?

The medical team to provide the necessary treatment and support to someone with bulimia nervosa includes:

• Psychiatrist: treatment mainly using medications
• Clinical psychologist or psychotherapist: treatment primarily with therapy ( as mentioned above)
• Dietician/ Nutritionist

When to See a Doctor

If your connection with food stresses you out and starts to interfere with daily life, it might be time to seek professional help. If you're reluctant to reach out, you can share your worries with a loved one. 

Seek treatment at the earliest if you have any of the following symptoms:

• Dizziness 
• Chest pain, palpitations 
• Fainting
• Acid reflex 
• Severe sore throat 

What is the Difference Between Bulimia Nervosa and Anorexia Nervosa?

People with anorexia are often underweight or sometimes very thin due to more restrictive eating patterns. They engage in extreme diets, exercises, and self-starvation to lose weight. Despite being thin, they think they are overweight or obese. On the other hand, people with bulimia nervosa often fall in the range of normal weight as they engage in cycles of binge eating, followed by purging to lose weight.

Helping a Loved One with Bulimia Symptoms

The tricky part of having bulimia nervosa is that you cannot conclude anything based on their body size, as they can be either at a normal weight or sometimes overweight. 

If a loved one is struggling with symptoms or you notice a few warning signs as mentioned above, try the following:

• Let them know that you are there for them and that you care about their well-being.
• Accept that they're not doing it by choice but is rather due to their mental health
• Educate yourself about their condition 
• Sit with them and try to talk with them about their concerns with an open and non-judgemental mind 
• Help them to find a mental health professional and offer to go with them for their appointments if they’d like 

Know How to help someone with an eating disorder?

How to Treat Bulimia Nervosa at Home?

In addition to medical help, try incorporating a few at-home or self-care tips:

• Learn about the condition to create more self-awareness. 
• Stay in touch with loved ones. 
• Be kind to yourself, and try to avoid checking yourself in the mirror often.
• Try to stick to the nutrient-rich plan as advised by your nutritionist. 
• Be mindful of the kind of exercises you do.
• Lastly, but most importantly, try to keep up with all your doctor's appointments and therapy sessions.

Conclusion 

Bulimia nervosa is an eating disorder that mainly affects adolescents and young adults. Repeated cycles of binge eating and purging behaviours are its main characteristics. 

One should look out for certain warning signs and other typical symptoms that can point to the possibility of bulimia nervosa. Fortunately, the condition is treatable through therapy, medications, and with support from loved ones.

References

Mayo Clinic. (2018, May 10). Bulimia Nervosa. Mayo Clinic; Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bulimia/symptoms-causes/syc-20353615

India Eating Disorder Treatment Resources & Information. (n.d.). Eating Disorder Hope. https://www.eatingdisorderhope.com/treatment-for-eating-disorders/international/india

Cleveland Clinic. (2022, May 16). Bulimia Nervosa: Signs & Symptoms, Complications & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9795-bulimia-nervosa

Bulimia nervosa. (2023, September 27). Wikipedia. https://en.m.wikipedia.org/wiki/Bulimia_nervosa

Physical and emotional side effects of bulimia on the body. (n.d.). Www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/322853#effects-of-bulimia

Eating Disorders and Romantic Relationships. (2018, January 19). Center for Change. https://centerforchange.com/eating-disorders-and-romantic-relationships-how-to-cope-when-your-partner-has-an-eating-disorder/

Long-Term and Short-Term Consequences of Bulimia. (n.d.). Eating Disorder Hope. https://www.eatingdisorderhope.com/information/bulimia/long-short-term-consequences

How to Help Someone With Bulimia. (2023). Withinhealth.com. https://withinhealth.com/learn/articles/how-to-help-someone-with-bulimia