Bulimia Nervosa: Understanding, Recognizing, and Seeking Help

Imagine someone who appears to be doing well based on every possible outward measure. They have a job or attend school, smile in photos, and show up for family members. However, privately they struggle with a pattern they cannot stop: eating until they feel like it is no longer possible to eat, and then, they experience overwhelming feelings of shame, guilt, and a deep need to “fix” what was just done. They have repeatedly assured themself that this will be the final episode. It isn’t.

Millions of individuals worldwide live in a silent state of bulimia nervosa. This is not a choice regarding a lifestyle, a phase, or simply a matter of willpower. It is a serious eating disorder, and there are treatments available.

The purpose of this article is to provide information about bulimia nervosa to help individuals either personally affected by this illness or caring for someone affected. An understanding of bulimia nervosa is necessary for recovery to begin.

What Is Bulimia Nervosa?

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by compensatory behaviours. Compensatory behaviours refer to actions taken to counteract the effects of binge eating. These include self-induced vomiting, abuse of laxatives or diuretics, fasting, excessive exercise, etc. The World Health Organization recognizes bulimia nervosa as a serious mental illness. In addition, the National Institute of Mental Health reports that bulimia nervosa results in significant medical complications.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for diagnosing bulimia nervosa are:

• A person engages in recurring episodes of binge eating - consuming large quantities of food in a short amount of time while feeling unable to control the behaviour.

• There are recurring compensatory behaviours that occur during the same timeframe as the binge eating behaviours. Examples of compensatory behaviours may include self-induced vomiting, misuse of laxatives or diuretics, fasting or engaging in excessive exercise.

• These recurring binge eating episodes and compensatory behaviours occur frequently enough to meet the frequency requirement - an average of at least once per week over the course of at least 3 months.

• A person’s self-evaluation is significantly impacted by their perceptions of their body shape and size. 

Importantly, bulimia nervosa is not a function of body type. Individuals with any body type can experience bulimia nervosa. Therefore, many cases of bulimia nervosa go unrecognized both by those suffering from the illness itself and by others close to the individual.

What are the risk factors for bulimia?

While virtually anyone can develop bulimia nervosa, there are some factors that appear to put some individuals at a greater risk.

Age and sex:

Bulimia tends to emerge during late teens or early twenties, however, while bulimia affects people of all sex and gender identities, cases may go undiagnosed because they do not fit the stereotypical female profile of having an eating disorder.

Psychological factors:

Individuals who exhibit perfectionistic tendencies, low self-esteem, impulsive behaviours or poor ability to manage their emotions are at a greater risk of developing bulimia. Also, individuals with a history of anxiety, depression or trauma tend to be at a greater risk of developing bulimia.

Social/cultural pressures:

Growing up in environments where thinness or body shape and appearance are highly valued (e.g., through media, messages from family members, sports culture, peer comparisons) increases the likelihood that the individual will develop disordered eating. Additionally, social media is associated with increasing levels of body dissatisfaction in young adults.

How does bulimia effect your body & mind if left untreated?

Untreated bulimia nervosa can lead to severe physical and mental health problems.

Physical health problems:

The repetitive nature of the binge-purging cycle causes incredible strain on your body. Purging repeatedly through vomiting, laxatives etc. can result in:

• Electrolyte imbalance which in extreme cases can disrupt your heart rhythm.

• Damage to your oesophagus and throat due to stomach acid.

• Tooth decay

• Kidney damage due to laxative abuse.

• Hormonal disruptions affecting fertility and bone density.

• Gastrointestinal issues including chronic constipation and irregular bowel movements.

These are serious side effects. In fact, some of the potential complications from bulimia can be fatal. Therefore, seeking out professional treatment is essential.

Mental health problems:

Emotional well-being is heavily connected with bulimia. The shame and stigma associated with the illness creates a sense of isolation. Most people with bulimia experience other mental health illnesses like depression, anxiety disorders, obsessive compulsive disorder, and substance abuse. 

The binging and purging cycle becomes a method of emotional regulation. Therefore, it can create a vicious cycle of being unable to stop without receiving professional help. This is not a matter of weakness. It is simply a habituated response requiring professional guidance to reverse.

How is bulimia diagnosed?

If you or a loved one thinks they might have bulimia, speak with a mental health or medical professional.

What to expect in a clinical evaluation

An initial clinical evaluation involves discussing eating habits and how one thinks and feels about food, body image, along with reviewing medical history and any present mental health symptoms. Since there is no specific test for bulimia, diagnosis is made by conducting a comprehensive clinical evaluation.

The clinician may also request blood tests and perform a physical exam to evaluate any physical health complications resulting from the eating disorder. Blood test result and physical exams will assist clinicians in determining what course of treatment would be best suited for each patient.

Many patients feel embarrassed when talking with professionals about their experiences related to bulimic behaviours. Please note that professionals are trained to provide compassion and not judgment. Honesty will allow an individual to receive the proper treatment for their needs.

Treatment Options for Bulimia Nervosa

Treatment for bulimia or other eating disorders is most effective when it addresses both the psychological and physical aspects of the illness. A combination of approaches is recommended.

Psychotherapy

Cognitive Behavioural Therapy (CBT) is one of the most evidence-based treatments for bulimia nervosa. CBT will assist an individual in identifying and changing the negative beliefs that contribute to the binge-purge cycle primarily the restrictive nature of food, the all-or-none type of thinking, and how food relates to an individual's emotions.

Dialectical Behaviour Therapy (DBT) is another approach that many people find helpful, especially when emotional dysregulation plays a central role. DBT teaches individuals skills on distress tolerance, emotional regulation, and improving interpersonal relationships, all these factors reduce the likelihood that an individual will engage in binge and purge behaviours.

Nutrition Counselling

By working with a registered dietitian specializing in eating disorders, a person can develop a balanced and flexible relationship with food. This means developing balance and sustainability- not restrictions.

Medication

There are several studies that suggest that certain medications (such as selective serotonin reuptake inhibitors [SSRIs]) can significantly decrease binge-purge frequency, especially when combined with psychotherapy. The use of medication is generally considered within a broader framework of treatment, under the supervision of a psychiatrist.

Inpatient Eating Disorder Treatment

Some individuals require more than outpatient care, especially when the symptoms are frequent and severe, medical complications are present, or previous attempts at recovery in a less structured setting have been unsuccessful.

Inpatient eating disorder treatment provides continuous support in a structured, healing environment. Programs that provide residential treatment are built around a multidisciplinary team that address every aspect of recovery - not just the eating behaviours, but also the physical, emotional, and psychological root causes of the binge-purge behaviours. These multidisciplinary teams may include:

• Psychiatrists responsible for assessing and managing medical and psychiatric aspects of the illness (e.g., depression, anxiety), prescribing medication when necessary, and providing overall oversight of the individual's medical status.

• Psychologists deliver evidence-based therapies (such as CBT and DBT) to help individuals identify and modify their thought processes and emotional responses that lead to binge-purge cycles.

• Nutritionists who assist individuals to establish a positive relationship with food, one that is not based on fear or excessive restrictions.

• Yoga instructor to guide body-positive movement to assist individuals in becoming reconnected with their bodies in a non-judgmental manner, often very beneficial for individuals whose relationship with exercise has become unhealthy.

• Physiotherapists supporting individuals' physical recoveries, address any musculoskeletal issues resulting from the illness and helping to re-establish normal movement patterns in a supervised and safe environment.

This multidisciplinary team meet frequently to discuss progress and make any changes to the treatment plans as necessary since recovery from bulimia nervosa is rarely linear. In-patient care allows patients to receive continuous monitoring of physical health, stabilization of medical concerns, and the intensive therapeutic work needed to begin lasting change. For many individuals this represents a critical turning-point.

Recovery does not end at discharge. This is often when support is most needed, therefore, it is essential that patients receive continued care, either as an outpatient after discharge or by participating in a structured day care program to protect the progress made during inpatient treatment.

How to Help a Loved One

Watching someone you love who has bulimia suffer through it is very scary. There are many ways to provide Support to someone struggling with bulimia. 

• Don’t let your first reaction be based on their weight or food choices.

Avoid commenting on weight or food choices. Instead focus on how they appear to be emotionally and express to them how much you care about them as a person. 

• Discuss your concerns with them - without pressuring them to change.

Find a calm and private time where everyone feels safe. Say something like; “Hey, I’ve noticed you seem really stressed lately. I care about you. I’m here to listen to you.” don’t give them an ultimatum. You can’t force someone into recovery. However, creating a safe environment for them will allow them to take control of their recovery and ask for help. 

• Help them get professional help.

Most people suffering from bulimia are too embarrassed to seek help by themselves. By offering to help find treatment options, making the first phone call, or attending the first meeting together, you can play a huge role in helping them get help. 

• Take care of yourself.

It’s extremely hard emotionally to watch someone you love deal with an eating disorder. Reaching out to a therapist or a family Support group for families of individuals dealing with eating disorders can help keep your emotional energy up and avoid burnout. 

Recovery is Possible 

It's an important fact that can become lost amid the illness - bulimia nervosa is treatable, and a full recovery from bulimia is possible.

Research consistently shows that with appropriate, sustained treatment, many individuals who have bulimia will go on to establish a positive relationship with food, their body and themselves. A full recovery from bulimia does not happen without some setbacks. However, these setbacks are simply part of the process.

The shame surrounding eating disorders causes too many people to remain silent for far too long. Know that seeking help for your eating disorder, is not a reflection of weakness. Reaching out for help for your eating disorder takes great courage.

A Note from Adayu

We hope that reading this has provided some insight and possibly some comfort if you are reading this for yourself or for someone you love.

For individuals whose symptoms have been so severe that their well-being would be threatened without the structure and support of an inpatient environment, or for whom outpatient care cannot meet their needs, there are times when the level of support and protection required may necessitate admission to an inpatient psychiatric unit. Adayu's inpatient program provides an interdisciplinary approach, including a psychiatrist, psychologist, nutritionists etc., to provide a supportive environment for the patient's recovery, followed by continuing care via outpatient services or day care programs upon discharge.

Our team is always here to discuss your options with you, whenever you’re ready.