Bulimia Nervosa. A Contemporary Analysis

Bulimia Nervosa means, ox-like hunger of nervous origin. It was first identified by Freud and was given that name in the 1980s to describe recurrent episodes of binge eating with attempts to get rid of calories and prevent weight gain. Bulimic symptoms include; vomiting, taking laxatives or diuretics and in 2016 excessive exercise was added to the list. There are other forms of bulimic behaviour which are rare, such as transfusing blood, taking large amounts of slimming medications and even using liquid food supplements to excess following a period of overindulgence. “Bulimia” is a word we also use to describe episodes of binge eating with purging in patients with anorexia.  However, this is not bulimia nervosa; if an individual is low weight a diagnosis of anorexia will generally prevail. Among people who are slightly under-weight it may be hard to decide whether they suffer from bulimia nervosa or anorexia. Only an expert can decide which kind of eating disorder they have, and we have to look at other things to be sure of a diagnosis. In this article when we use the word “bulimia” we are referring to the bulimia of normal or excessive weight. Like all the other eating disorders, bulimia has serious life-threatening effects both physically and emotionally. The various types of bulimia are listed below.

Excessive intake of food called “binge eating”, regularly, with compensatory purging to prevent weight gain.  The amounts of food eaten will be objectively large and probably eaten fast or in a mindless way. They have irresistible cravings and the food eaten will most probably be forbidden, i.e. considered fattening. The behaviour will have been present for several months. People will usually conceal their behaviour from other people and will be ashamed of it. People often promise to stop, but it somehow doesn’t happen. Experts disagree what “binge eating” means because one person’s binge is just someone else’s nice meal. So, we must accept that eating to excess is a very subjective thing with some very anxious people believing that they have binged after eating anything which is a forbidden food. There are also differences between one person and another. Some people binge and purge several times a day and some only once or twice each month. Research shows that the frequency of binge eating episodes among bulimics varies from 1 per week to 46 times. The average is once daily, with the number of calories consumed in the binge ranging from 1,200 to 11,500 for people with typical bulimia. Foods typically eaten during a “binge” will include biscuits, chocolate, crisps, bowls of cereal, large amounts of toast with butter, chips, cakes, tubs of ice cream etc. Eating continues until the urge to eat is gone, tension is reduced, physical satiation is reached, often to the point of pain, or the person is interrupted. In its most severe form, the sufferer eats to the point of physical damage – they can rupture the stomach or tear the tube that leads from mouth to the stomach.  Rarely, people with severe bulimia have eaten raw meat, dog food, or food from other people’s rubbish bins. The cycles of bingeing and purging can occur many times each day.  There is no “average”.

This is bulimia which does not quite fit the criteria above. Perhaps the purging behaviour doesn’t happen regularly enough, or the overeating is not excessive.  There are people who purge without having overeaten at all to weight rather than preventing weight gain. We call this “purging disorder” and it is not easy to treat.

This is how we describe people who overeat and purge for weight control, who also overuse drugs and alcohol, or who engage in other forms of addictive behaviours to help them to manage stress and life in general.

Excessive exercise may be present in the other forms of bulimia or exists in people who do not vomit or take laxatives but exercise excessively and compulsively to deal with overeating.  Exercise addicts often deny that they have a problem and assert that they just love exercise and it makes them feel good. Only an eating disorder expert can distinguish an exercise addict from an exercise bulimic. I make my husband wake at 5 and take me to the gym before we go to work. Then at lunchtime I go for a walk if I have eaten anything. I play tennis about 3 nights a week even though the kids ask me to stay home with them. At the weekend I get up early and go outdoor swimming in the lake. I go crazy if I have to stay home. I can’t allow myself to eat otherwise.

Is where people with diabetes withhold insulin because this will make them lose weight. It is a dangerous, potentially fatal condition and we write about it elsewhere in our information pages.

Men and women of all ages and lifestyles can suffer from bulimia nervosa. The reasons why more women than men suffer from eating problems is probably due to the importance that women have always attached to appearance and the pressures they face to achieve an unrealistic body size. Women are more amenable to pressures for weight control, most probably because they are attuned through socialisation to seek approval from others for their emotional survival. The average of onset for females is mid-adolescence, almost always after they have been on a weight-loss diet. Bulimia shows up later in men who have some protection from poor body image during teenage years. While the majority of those with bulimia, as with any eating disorder, are women, men do struggle with binge eating and its associated features. Historically, the ratio of women to men with eating disorders like bulimia nervosa and anorexia nervosa has been calculated at roughly ten to one Weltzin, 2005.  Men are less likely to come clean about having bulimia, which distorts the statistics. We know that it is common among males with a past or current history of alcohol abuse. Bulimia in men is rife in sport due to increasing pressures to control diet as well as training schedules. We learn, anecdotally, that bulimia is common among males who engage in body building as they skew their eating habits to build muscle and at the same time lose body fat. Research suggests that almost half of all people with bulimia will not recover without treatment. This means that there are many people from all walks of life who are walking around with a secret problem. Bankers, lawyers, students, teachers and even doctors may be sufferers, nurturing a forbidden secret, unable to stop. Some people with bulimia were once anorexic and have subsequently regained their weight, started to binge eat and adopted patterns of overeating and purging. But most people with bulimia were never anorexic. There is stigma attached to all the eating disorders despite a great deal of publicity. The Princess of Wales in the 1980s did much to bring bulimia to public attention, as did many other celebrities such as Jane Fonda. There have been males who admit to eating distress such as the politician John Prescott and the singers Elton John, Lady Gaga and Gary Barlow describing their experience of bulimia. If statistics are needed there may be lifetime incidence of 3% for females in the population and the prevalence of bulimia is greater among obese women at about 9%, confirming the greater likelihood of disordered eating among people who are overweight.

There is a mantra which is worth remembering; there is no single cause of any eating disorder. All eating disorders emerge from dieting behaviour, so dieting has some role in triggering a bulimic pathway. This can best be understood by considering the side effects of dieting. Several key studies: The Minnesota Starvation Studies, studies by Herman and Polivy and accounts of starvation in various historical contexts such as the Holocaust – demonstrate that dieting or starving has many long-term side effects, the most common being cravings and not being able to regulate eating. Dieting also leads to depression and disturbances of body image. For a review of the psychological literature on dieting please contact NCFED. Established bulimia is associated with the following risk factors which include, in no order of importance:

• The culture and exposure to pressures to lose weight and unhelpful eating messages.
• Emotional neglect in childhood.
• It was a common myth that bulimia is a sign of sexual abuse. The prevalence of sexual or physical abuse among bulimics is no greater than we would expect in a population of normal eaters. We do however look for other kinds of traumatic experiences such as dyslexia, bullying, family tensions and loss which have caused unbearable stress. Long term stress leads to hypervigilance and emotions which can become over-aroused in a variety of situations. We estimate that almost 8 in 10 bulimia sufferers suffer from full or partial Post Traumatic Stress Disorder (Vandereycken) and the function of bulimia in this case might be to distract oneself from emotions that are excessive and dangerous.

Every day I came home from school I looked up at the window and if the curtains were closed, I knew that my mum was in bed. I would try and find another place to eat my supper and I would eat as much as I could in case there was no breakfast the next day. Bulimic male aged 50.

• Family styles where there is a lot of drama or other addictive behaviour and lack of stability.

My father was a drunk; we would have to keep out of the way and be good or he would take it out on mum. She always tried to keep the peace. Then he just took off and we were left to fend for ourselves. Bulimic woman aged 35

• Too much weight concern in the family. Dieting mothers are associated with daughters who have body image issues and bulimia has been associated with weight comments and weight loss encouragement by fathers.

Jenny is 14 years old and overweight. Her father told her that she needed to lose a few pounds and would give her some money if she did. Jenny tried to diet and found it hard, so she hit upon the idea of vomiting her evening meal. Within a short space of time she found it difficult to eat anything without having to get rid of it. She has discovered that the more she purges, the hungrier she becomes, and she has come to see a therapist in a very desperate state.

• Personality style such as Risk-taking, Impulsive and Perfectionist.
• Difficulty with expressing and managing feelings – which might be associated with long term stress or difficulties in the family.
• Difficulty trusting and getting emotional needs met by other people: Most people with bulimia find it hard to express their views about many things that are important to them; this is an observation we have made after many years of working with patients.

I am jealous because my sister is flirting with my boyfriend, but I can’t tell her. I sit and watch it happening and I don’t say anything. It’s wrong to be jealous isn’t it and she would tell me that I’m pathetic. Bulimic woman aged 29.  I waited and waited for my dad to show me some thanks for taking care of him and he never did. Bulimic male aged 42  We all lost our voice, didn’t we? Bulimic doctor at workshop aged 32

• Anything that has caused poor body image such as a history of weight gain and being fat- teased.

I had kidney problems when I was 4 and I had to take steroids. I can still remember the fat on my waist spilling over my trousers. There is no need to look for a cause of bulimia. We are more interested in discovering the risk factors and how they may have undermined each person’s ability to flourish in life. It is also important to find out what was going on just before the bulimia started. It helps us to learn what might be “missing” that allowed the eating disorder to take hold. Bulimia usually emerges at a time of personal stress. It might be the breakup of a relationship or difficulties coping at school.

Weight gain is common with people who have bulimia nervosa since they are likely to ingest and absorb thousands of calories before these are expelled. The average number of calories absorbed as the result of an average binge purge event is 1200. Some bulimics believe that purging can continue until a marker is expelled and that everyone has “gone”, which is a myth. I eat something red and when I see it come up, I know everything has gone. Laxatives are not a good weight control strategy because most calories taken in during an overeating event are absorbed before the laxatives take effect. There is a common delusion of immediate weight loss after purging both in vomiting and in laxative abuse, possibly due to water loss and emotional relief. Sometimes I overdo it and can’t go to work. I don’t mind the pain it shows me that the pills are working well. If a bulimic is not overweight, it is because of restraint behaviour they manage to exert during other times. However, food restraint, strange dietary practices and fears of eating normally and regularly “in case once I start eating, I cannot stop” – make bulimia worse. Bulimics may do any number of things to restrict calorie intake and minimise the risk of weight gain. This could include skipping meals, ingesting large amounts of caffeine, eating dozens of apples, avoiding carbohydrates, taking stomach fillers and drinking a lot of water before meals. All this achieves is that it contributes to more cravings, blood sugar fluctuations and disrupted moods.

Trying to keep this simple: 1     Some experts describe bulimia as an addiction because it is compulsive and because of the effects of binge eating and purging on the opioid (addictive) brain.  2    Others suggest that the behaviour of overeating and purging represents a need followed by the repudiation of that need. Buckroyd, Professor J. – representing a disorder of attachment in someone whose early needs have not been met.  In consequence, they have not developed the apparatus (physical and emotional) to self-soothe in more helpful ways citing the work of Allan Schore and others 3     Bulimia is a behavioural disorder maintained by factors such as faulty thinking processes such as the belief that purging prevents weight gain. Faulty thinking styles such as all or nothing thinking contribute to negative emotions which keep a person trapped a bulimic loop. 4     Some theorists believe that bulimia is a relational disorder since it emerges at a time when someone is experiencing stress with other people. It represents a failure of being able to manage relationships effectively. 5     The schema view of bulimia  Waller, Glenn. Jeffrey Young suggests that bulimia is a way to manage powerful negative feelings in someone who has deep and irrational negative beliefs about themselves. Bad feelings, such as anger and anxiety  provoke these bad beliefs and elicit a great deal of shame. Binge eating and purging is, according to this model, a global distraction-strategy in someone who is not able to manage their emotions in more helpful ways. 6      Most suffers and therapists alike think that bulimia is a sign of psychological disturbance. Bulimics are depressed, anxious, guilty, impulsive and obsessional, but this may change when the illness is treated and nutritional imbalances are corrected. People choose bulimic strategies at a time in life when they are stressed and are unwise. The behaviour then becomes heavily reinforced and the original stress is in the past 7     Several years ago, bulimia was linked with depression and the treatment of choice was antidepressant medication. Serotonergic drugs such as Prozac can be helpful for some cases, although there is a tendency to relapse when medication is discontinued unless the treatment is combined with appropriate psychotherapy.  Our personal observation of thousands of cases of bulimia over the past 30 years suggests that less than a handful of people we have treated needed drugs. All these explanations may have some part to play in maintaining the bulimic illness. People who suffer  feel greatly ashamed of themselves. They view anorexia as a worthy illness; a form of purification and they view bulimia as the Cinderella of eating disorders, dirty, shameful, disgusting and evidence of personal weakness; which adds to their poor self-regard. Tanya was a 21-year-old student who dieted to be attractive and compete, as she saw it, with the more popular girls in her class at school. In the early stages she binged and vomited occasionally and managed to complete her A-Levels and go on to University. But the binges and the hungers became worse. She waited until everyone in her family went to bed and then she started on her binge of specially bought foods, eating mechanically until she felt ready to go to sleep. She set her alarm for 2 hours later and then got rid of what she had eaten. She believed that it was only by having her nightly binge that she could get through the next day at all. The lack of sleep at night took its toll and eventually she was unable to complete her degree. When she came for help, she was also terrified of going to bed at night without her comfort foods.

Here is what some people say about bulimia Constant thoughts about food – how to avoid eating it, how to get a binge food, how to get people out of the way so that you can overeat, thoughts and images about food which lead to fear and distress. Constant thoughts about weight, feeling fat and ugly. Often purging will help you to feel instantly thin even though in reality they are not. A sense of fear and foreboding, uncertainty and anxiety about everyday food occasions that other people can deal with – such as going to restaurants or social occasions. Eating normally in public, only for this control to break down when you are alone. Food feeling like a constant threat, both a friend and a foe, having to be constantly vigilant, not knowing when you have had “one bite too many” and will have to get rid of it. A sense of being different from others, carrying a guilty secret around with you. Feeling lonely, different and insane. Bingeing feels as if you have been taken over and possessed by someone else and not even remembering all that you have eaten. Bingeing and purging changes your mood, you may find unbearable tension before binge purging, and may be sleepy and calm or elated afterwards as if you can “get on with things”. Bulimic behaviour being something you have to do ritually and get over with just to feel normal. Feeling angry and stupid that you can’t stop; letting yourself down over and over again. A sense of life being a constant struggle. Guilt and shame about all the behaviour that supports bulimic behaviour, such as spending too much money, wasting food, stealing money or taking food from other people’s food supplies. In someone without bulimia, trying to resist purging would feel as if you had knowingly eaten poisoned food that would slowly rot you from the inside, and your life depended on getting it out of you.

Without treatment, people can remain bulimic for many years and there is a heightened risk of suicide among sufferers. Even if a sufferer stops purging which some do in an attempt to take better care of themselves, they might continue to eat compulsively at times.

 I was horrified to find out that my daughter had heard me being sick and caught her listening outside the bathroom door. So I stopped, but I carried on having horrendous binges.  We know that some people will be more likely to recover than others. Factors include difficulty with purging, early intervention and having supportive relationships. Poor prognosis is associated with many factors such as personality disorder, ease of purging, early obesity, and the excessive use of alcohol and drugs. If I encounter a patient who finds it very easy to vomit as some do, I am seriously worried about their willingness and capacity to stop.  It takes me about 2 hours to get rid of everything and I’m tired of living like this. Vomiting? oh its easy. I just think about it and it comes up. I have to go from one shop to the next to buy laxatives and I make this excuse about getting them for someone else. Then I hide them. It’s such a waste of my time. It would take several pages to document the physical and emotional effects of purging so the reader is referred to Sick Enough; A Guide to the Medical Complications of Eating Disorders by Jennifer Gaudiani. Bulimics want to believe that the only consequence of purging is calorie expulsion in the case of laxative abuse and vomiting. Every systemn in the body is affected through metabolic changes associated with purging including the heart, liver, kidneys, brain, endocrine function, the effects on the biome (gut bacteria) and integrity of the gastrointestinal system. There are cellular changes of the stomach and oesophagus that may arguably lead to functional disorders like spastic mega-colon in the case of laxative abuse as well as cancer in the case of bulimia. The more commonly cited signs of purging would be marks on the hand (Russell’s sign) and swelling of the parotid glands beneath the tongue. Dietary chaos leads to changes in the neuro-chemicals of mood and it is expected that people with bulimia are deficient in serotonin, that protects against depression. Surges in blood glucose as a result of binge eating to have significant effects on the stress system which is constantly on high alert. Laxatives and to some extent vomiting sweep large amounts of electrolytes like potassium from cells causing kidney damage and cardiac problems. Cells depleted of potassium fail to burn energy effectively so, purging causes easy weight gain. Laxatives damage the gut wall and affect liver function.

Before: The most common triggers for bulimic events are hunger, low mood including fear and anxiety, feeling ineffective, needing to say something and not saying it, feeling lonely or tired and feeling fat. Sometimes a trigger might be a certain time of the day which merits further understanding. Afterwards: People experience a range of different feelings after purging. They may be elated, exhausted, remorseful, spaced out, energised and motivated to get going, or sleepy. Some feel able to carry on the day as normal, others feel that they have failed in their intention to have a good day and they carry on overeating and purging for the rest of the day.  Some people swear that they will never purge again but it somehow doesn’t happen. A functional analysis of eating over a long period of time will help us to identify triggers and deal with them through the process of therapy. A food diary will also help us to know what else is troubling the person. By looking at a food diary we come to learn if they have any other mental health issue such as an anxiety disorder or, difficulty coping with relationships.

Treatment has to be adapted to the needs of each person because there is no typical bulimia sufferer. People purge in different ways, respond to different triggers, experience a different aftermath and bring different mental health difficulties as well as emotional resources to their struggles with control of food. It is misleading to say that we need to treat bulimia. We need to treat the person who has the disorder. We do not intend to force them to stop purging; we have to replace binges and purges with something else. After good therapy, a former bulimic will feel sufficiently robust, happy and effective so that they can leave bulimia behind. The aim of bulimia treatment is to help the person lose their cravings and eat a wide variety of foods without anguish or fear of weight gain, and to be able to take care of themselves with food and in other ways. Whatever the bulimic symptoms are doing for them they will be able to get in healthier ways. Bulimia treatment is holistic and targets the maintaining factors of the illness, not the causes. A good thorough assessment is crucial. People with eating disorders respond well to therapists who show understanding and expertise of eating disorders and sensitivity to the personal experience of someone who contains a lot of shame. At the NCFED, we favour thinking of bulimia treatment as a form of coaching rather than therapy. The following is an overview of the factors that we can target but this overview will not explain the depth and range of strategies that we can harness to bring about change because this is part of the strategies we call upon. We target: Ambivalence about change The multiple effects of dietary chaos Unhelpful thoughts which generate behaviour, including horrible thoughts about the body Emotional deficits And Relapse Prevention

Most bulimics are conflicted about change. They may fear weight gain or wonder how they might get to eat their favourite forbidden foods if they must control their eating. To stop purging means taking responsibility for what and how they eat, something that they have lost the ability to do. Purging, however, is not just about food. Bulimia has become a mood regulator so they may wonder how they will cope with life if they have no other means of dealing with their feelings. Bulimia can be a way of coping with other difficult situations. Take the case of Jane Jane came for treatment for long standing bulimia which left her housebound.  Before starting treatment, I asked her what might happen if there was a magic wand and there was no bulimia any more. I will have a difficult choice she said. I could go to work but then..oh I didn’t think of that… who would stay at home to look after my invalid mum… Raging emotions erupt in the body and then disappear down the toilet bowl: Marya Hornbacher  I would rather be thin and still have my bulimia than cured and fat like this.

Nutritional rehabilitation corrects some of the physical imbalances that cause abnormal cravings, metabolic harms and low mood. This can be delivered by a suitably trained psychotherapist and includes a range of skills to increase willpower and restore control over appetite. Nutritional interventions support psychological treatment and help someone feel better very fast. I didn’t realise what effect low blood sugar was having on me, on the way home I cried because for the first time it made sense of what I had suffered;  the cravings, feeling miserable and tired all the time. Nutritional rehabilitation attends to the desperate need to purge which interferes with treatment, but which must be respected at the same time. We encourage laxative takers to reduce the number of laxatives they take, slowly, to reduce rebound water retention and they are given appropriate medical support if it is needed.

Enhanced cognitive styles of therapy gently disentangle the unhelpful thinking that maintains bulimia. This may range from correcting misunderstanding about food and how it works in the body, and we work on the perfectionist attitudes that maintain the bulimia. Cognitive therapy boosts self-worth, which is a crucial aspect of therapy and this in turn helps reduce the intense focus on appearance and enables people to take care of themselves in much better way. I stopped saying “should” to myself all the time.  And when the old bulimic thinking about having a binge comes into my head, I can ignore it, I didn’t think it would be possible. I didn’t imagine that I would be able to have a biscuit and stop at one. It’s a miracle.

Emotional resilience training helps people manage their emotions without turning to food. Relationship skills coaching to deal with conflict such as assertiveness training helps people to feel more in control of their lives. I have needed to purge for about as long as I can remember. Then one day after I started working with you, I felt really angry about something I didn’t know I was cross about, so I ate something and I went upstairs to purge. Instead I started to cry and cry and I haven’t needed to purge ever since. I’ve learned that I have the right to make mistakes and I have the right to change my mind and I have the right to stop being dependent on my parents to feel OK about myself and I’m like a different person.

One thing is clear, for treatment to work people will need to stop purging completely but many want to keep it as an option. in which case there is a high risk of relapse.  Relapse prevention is a specific psychotherapy hat can be very effective in protecting people from the return of symptoms. Relapse can creep up on someone unawares, such as making a decision to go om a diet. People with bulimia come to terms with the fact that everyone overeats from time to time.  If they continue eating normally and healthfully, no damage will be done. If I find myself saying You shouldn’t have eaten that!  I find it easy to relax and calm down.

Hospital treatment is needed for only a tiny minority of cases; usually those who have failed outpatient therapy or who have severe depression. Although the NICE Guidelines for eating disorders recommend an initial trial of antidepressants for bulimia, we believe that this is rarely good advice. People who recover without the use of drugs have a great sense of achievement and well-being. There is a tendency for psychiatrists to over-medicate people who try to recover whilst in a state of sedation. This might be a short-term fix but may interfere with therapy.   Hospital treatment is needed for only a tiny minority of cases; usually those who have failed outpatient therapy or who have severe depression. Although the NICE Guidelines for eating disorders recommend an initial trial of antidepressants for bulimia, we believe that this is rarely good advice. People who recover without the use of drugs have a great sense of achievement and wellbeing. There is a tendency for psychiatrists to over-medicate people who try to recover in a state of sedation which might be a short-term fix but may interfere with therapy. Having said this in severe cases of bulimia with other mental health issues like social phobia or OCD, a person may benefit from having drugs alongside therapy. Medical advice is mandatory for this. Finally, it is always better to treat bulimia in the real world where coping strategies can be tested, rather than in an institution. Some addiction services take bulimic patients over an extended period for 12-step treatment. We do not know how effective these programmes are and we do not favour naming people with bulimia as addicts, or addicts-in-recovery. It is possible to recover completely from bulimia.

CBT (eating disorder specific) is the gold standard treatment for bulimia and protects against relapse. These days we use expanded forms of CBT which also include strategies for managing emotions. These expanded forms include Acceptance and Commitment Therapy which draws on Zen Buddhism, Cognitive Emotional Behaviour Therapy to manage emotions and Schema -Focussed CBT which deals effectively with the core beliefs which cause shame misery. CBT-E is a manualised form of CBT created by Professor Fairburn and his team which can be delivered by specifically trained psychotherapists. DBT or Dialectical Behaviour Therapy is a treatment of choice for bulimics who also self- harm and who have extreme difficulty managing and tolerating negative feelings; sometimes due to prior loss or trauma. When people with bulimia have useful strategies for managing their feelings, they find it easier to change. IPT Interpersonal Therapy, assumes that relationship problems are at the heart of the problem. There is no focus on symptoms but the therapist will focus on a key problem relationship. Not many therapists are trained to deliver this therapy. NLP Neurolinguistic Programming favoured by NCFED is a powerful behaviour change therapy with no strong evidence base, but a very strong following among increasing numbers of psychologists, counsellors and personal coaches. Positive Psychology: (Seligman) Provides evidence-based strategies to boost self esteem, release depression and help clients to flourish. Third Wave Energy Therapies such as EFT (tapping) and EMDR (eye movement desensitising and reprocessing) address the unprocessed traumas causing the emotional maintaining factors in bulimia. Hypnotherapy: has been viewed historically as useful  for any behaviour disorder but there is no evidence for its effectiveness. Self-Help Groups: Group approaches help a person with bulimia to feel less alone. But we believe that targeted and personalised guidance is the only way for someone to recover and be protected from relapse. Bulimia Workshops: NCFED offers a Beat-Bulimia workshop which has kick-started recovery in many people who have attended. See our workshops for details.