Bulimia Nervosa
Today, we are revisiting and updating our post on Bulimia Nervosa. Bulimia is one of the more well-known eating disorders, impacting 1.5% of women in their lifetime and 0.5% of men [6]. Like other eating disorders, bulimia nervosa impacts individuals across the race, gender, sexuality, and ability spectrum. The lifetime prevalence of bulimia in trans men is 3.2% and trans women 2.9%, with Black teens being 50% more likely to develop bulimia than their white counterparts [7]. In this post, we are reviewing the diagnostic criteria, symptoms, medical complications, and treatment.
Bulimia Nervosa
Diagnostic Criteria
Recurrent episodes of binge eating are characterized by the following:
eating in about 2 hours an amount of food that is larger than what most people would eat under similar circumstances in a similar amount of time
a sense of lack of control over eating during this episode (feeling as if one cannot stop or control how much or what they are eating)
Recurrent inappropriate compensatory behaviors to avoid or prevent weight gain (i.e. self-induced vomiting, misuse of laxatives, diuretics, other medications fasting, or excessive exercise).
Both the above binge eating and inappropriate compensatory behaviors occur on average, at least once a week for 3 months.
Self-evaluation is unduly influenced by body shape or weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa [1].
Severity ranges from mild to extreme and is based on the frequency of compensatory behaviors.
Perceived Binge vs. Subjective Binge
It’s important to note the difference between a perceived and subjective binge. A perceived binge may elicit a feeling of fullness that is considered uncomfortable, eating more than was planned, or eating after a long period of restriction* and then perceiving the quantity consumed as “too much”. A subjective binge falls in line with the DSM-5 definition. Both are valid experiences and both experiences deserve support and care.
Binges can occur from undereating/restriction. Restriction/undereating can lead to an intense hunger that contributes to a binge, then purging, then restriction again to “make up for” the binge (sounds like the Restrict/Binge Cycle).
Symptoms of Bulimia Nervosa
food restriction or fasting
consuming large amounts of food in a short period of time
using self-induced vomiting, diuretics, laxatives, enemas, diet pills, excessive exercise, or other medications to induce purging
fear of weight gain
feeling out of control around food/feeling shame over the amount of food eaten
eating in secret or as inconspicuously as possible
trips to the bathroom after/during meals
dry skin and brittle nails
withdrawing from normal activities
eating in secret or as inconspicuously as possible
Medical Complications of Bulimia Nervosa
electrolyte abnormalities
nutrient depletion
rebound constipation
amenorrhea (in those who menstruate)
acid reflux disease
sore throat and swollen salivary glands
swelling of cheek/jaw area
dental issues (stains or discoloration)
heart palpitations and/or chest pain
What Causes Bulimia Nervosa?
Like all other eating disorders, a variety of biological, psychological, and social (bio-psycho-social) components influence the development of Bulimia Nervosa. Biological factors range from genetics (a woman with a mother or sister who has bulimia is 4x more likely to develop bulimia as well [4].) to personality traits. Perfectionism, low self-esteem, co-occurring conditions like mood disorders [5], and trauma play a significant role on the psychological side of things. The social component includes social media, social pressure to fit into ‘the thin ideal’, and diet culture (of course!).
Treatment
Treatment for Bulimia Nervosa is dependent on the level of care needed. Due to the nature of medical complications, medical treatment, and nutritional rehabilitation/therapy are important. Depending on the severity, this can be done in an inpatient or outpatient setting. Like other eating disorder treatments, psychotherapy in the form of Family-Based Treatment (FBT), Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Acceptance and Commitment Therapy (ACT) can be beneficial for recovery
When working with a dietitian, treatment goals often include eating smaller amounts of food more frequently to stop this cycle from continuing. Emotions can play a role in this cycle and calm environments for eating are encouraged. Activities after meals are promoted to help clients find something engaging to do rather than be at risk for a purge to occur [3].
Goals of Treatment
The goals of bulimia nervosa treatment include:
Reducing and eliminating binge eating and forms of purging whenever possible
Treating physical complications that may occur
Supporting the client in motivation to change and participation in treatment, providing nutrition education and eating pattern support
Help clients assess and change thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder that appears dysfunctional
Treating associated psychiatric conditions
Enlist family support and counseling when appropriate, and prevent relapse [3]
Seeking Help
Our team of therapists and dietitians specializes in helping individuals with diagnoses on the eating disorder spectrum. If you’ve been struggling with your relationship with food, exercise, or your body, you deserve help! Reach out to our team today!
This post is for education purposes only and should not be used as a substitute for treatment for an eating disorder. If you believe you have an eating disorder or would like to talk to a team member about dietetic or therapeutic services, please fill out the contact form and someone will get back to you within 72 hours.
Sources Used:
[1] Setnick, J. (2013). The eating disorders clinical pocket guide. 2nd Ed. Snack Time Press.
[2] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.
[3] Yager, J. et al. 2010. Practice guideline for the treatment of patients with eating disorders. 3rd ed. American Psychiatric Association. https://www.researchgate.net/publication/285994599_Practice_guideline_for_the_treatment_of_patients_with_eating_disorders_third_edition#read
[4] Weatherston-Yarborough, L., LPC, CEDS-S, NCC. (n.d.). What is bulimia? | Eating Recovery Center. Eating Recovery Center. https://www.eatingrecoverycenter.com/conditions/bulimia
[5] Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299.
[6] Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358.
[7] Nagata, J. M., Ganson, K. T., & Austin, S. B. (2020). Emerging trends in eating disorders among sexual and gender minorities. Current opinion in psychiatry, 33(6), 562–567. https://doi.org/10.1097/YCO.0000000000000645
