Bulimia nervosa is a serious psychological eating disorder that can be life-threatening if left untreated. Individuals with this condition have a fear of putting on weight and resort to unhealthy measures to get rid of food they have eaten, such as excessive exercising, taking laxatives or forced vomiting. Sufferers are often insecure and may rely on food as their main source of comfort.
Characteristics of this disorder typically include strict dieting followed by binge-eating, in which sufferers will compulsively eat a large amount of food in a short space of time. This is often driven by a desire to find comfort from issues such as stress and depression. The foods consumed during a binge are usually comfort foods, such as sweets, cakes and chocolate - items that have very high fat and sugar content. People with bulimia tend to have an abnormal or unrealistic fear of these foods due to their association with weight gain.
Following a binge, it is common for people with bulimia to feel intense guilt and shame and so will look to purge shortly afterwards to get rid the food. This is usually done in secret, and in some cases sufferers will purge on a regular basis even if they haven't binged. Purging can become addictive and is often used as a means of regaining control after giving in to food.
This page will explore bulimia nervosa in more detail, highlighting causes and symptoms of bulimia as well as the methods used in bulimia treatment. Counselling for bulimia is particularly effective for helping sufferers to overcome their bingeing and purging habits.
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The purge and binge cycle
Bulimia nervosa is characterised by the destructive binge and purge cycle, which is influenced by the restriction of food to keep weight down. Ironically however, as sufferers will find, the more strict and rigid a diet, the more likely they are to binge. This is because the body responds to starvation and lack of nutrition with powerful cravings. As the tension, hunger and feelings of deprivation increase, so does the compulsion to eat.
Often this compulsion sees individuals reach for forbidden foods, and this is often what triggers an all or nothing mindset - leading to a sudden binge on a large quantity of unhealthy foods beyond the point of feeling full. The relief and comfort this behaviour brings is short-lived, and soon after, guilt and self-loathing will set in. Purging this food is often a way of making up for the sudden loss of discipline.
Unfortunately, purging only reinforces binge-eating - it becomes an easy way out if control is lost again. People with bulimia do not realise that purging is not a simple means of wiping the slate clean, and the unravelling of emotions that this behaviour brings adds to the complexity of their illness and enhances their need to binge.
Who gets bulimia?
According to Patient.co.uk, bulimia nervosa affects men and women from all walks of life. It is very rare for young children to develop the condition, and it tends to be more common in women than men - particularly between the ages of 16 and 40. Evidence suggests around one in 100 women in the UK have bulimia at some stage in their life, and it most commonly starts around the age of 19 years.
Signs and symptoms of bulimia
It can be hard to recognise if someone is suffering from bulimia nervosa, so the condition can remain undetected for many years. This is because the sufferer is usually very secretive about their means of 'getting rid of food' (purging), and they are unlikely to experience the dramatic weight-loss commonly associated with anorexia. Due to this, the illness itself can only be detected and diagnosed if the individual shows several of the signs and symptoms covered below.
Signs of bulimia
As well as regular bingeing and purging, another common sign that someone has bulimia is their extreme attempts to keep their weight down - chewing gum, taking slimming pills or smoking to suppress their appetite. People with bulimia are also likely to exercise and weigh themselves excessively, and may become obsessed with checking their body shape in mirrors and reflective surfaces. In some cases, sufferers will begin to worry more about their weight as a result of constant bingeing, and will develop obsessive difficulties, such as having to stick to rigid routines or times.
Above all, sufferers will strive to conceal their bingeing and purging habits from friends and family. Not only will they be likely to disappear after meals - usually to visit the bathroom - they may even start withdrawing themselves from social situations that involve food altogether. Isolation is a common sign that someone has developed bulimia, as is spending large amounts of money on food, signs that vomiting has occurred in the bathroom and the presence of laxatives.
Symptoms of bulimia
The following symptoms of bulimia highlight how the condition can greatly impact the health and well-being of an individual both mentally and physically.
Physical symptoms of bulimia
- frequent fluctuations in weight
- blistering on the knuckles that can result from pushing fingers down the throat to induce vomiting
- frail hair and nails
- frequent stomach pains
- puffy cheeks caused by repeated vomiting
- discoloured teeth
- tiredness and feeling weak
- broken blood vessels in the eyes
- loss of libido
- difficulty sleeping
- changes to the menstrual cycle.
Psychological symptoms of bulimia
- an unhealthy obsession with food and eating
- depression and anxiety
- unrealistic views on body image and weight
- impulsive behaviour
- mood swings
- lying and secrecy
- feeling out of control.
Causes of bulimia
Currently there is no identified single cause of bulimia nervosa, however it is thought that a combination of factors can influence its development. A common reason is an overriding fear of getting fat, but there are several more complex feelings and emotions linked to the condition. In most cases, people with bulimia will have trouble managing their emotions in a healthy way, and the act of bingeing and purging is often used as a coping mechanism and a way of dealing with troublesome emotions.
Pressure on body image
There is a great deal of pressure from society for people to be thin and conform to a specific image of beauty. Bulimia usually begins with body dissatisfaction, particularly in young women who are bombarded with media images of an unrealistic physical ideal. It can also occur as a result of trying to pursue a particular profession. Ballet dancers, gymnasts, models and actresses will face a great deal of pressure on body image. Many people will fall into the cycle of bingeing and purging when the pressure to diet becomes too much.
Individuals who have low self-esteem and consider themselves to be worthless and unattractive are more at risk of developing bulimia. This is because losing weight is often associated with feeling happier and more confident. Low self-esteem can be triggered by a variety of things, including perfectionism, a critical home environment, depression and childhood abuse.
History of trauma
It is common for people with bulimia to use bingeing and purging as a way of managing feelings and experiences related to post-traumatic stress disorder (PTSD). A great number of women who have bulimia will have experienced abuse or trauma at some point in their lives, whilst others will have grown up with parents who struggled with a psychological disorder or abuse problems.
Stressful situations or life events can trigger bulimia nervosa, such as the death of a loved-one, puberty, divorce and redundancy. Some people may feel overwhelmed with stress following a long-term physical illness, or as a result of ongoing family and career problems, exam pressure, arguments and criticism.
In addition, bulimia like all eating disorders can exacerbate stress, and the effect it has on physical and mental well-being. Worrying about weight can increase anxiety and may lead to feelings of low self-esteem that can elevate stress levels. This is an exhausting cycle, and regular bingeing and purging becomes the only source of escape and comfort for bulimia sufferers.
Mental health issues
Often people with bulimia will show signs of psychological problems such as depression and anxiety disorders (i.e. obsessive compulsive disorder and personality disorders). Again their unhealthy eating habits are a means of coping with unhappiness, but when bingeing and purging does not make them feel any better, the cycle continues, and their mental health issues escalate.
Although research has been inconclusive, it is thought there is a genetic predisposition to the development of eating disorders such as bulimia nervosa. Evidence has shown that individuals with relatives who have bulimia are four times more likely to develop the condition than those who do not have a relative with the condition. Chemical imbalances in the brain are considered a key genetic abnormality linked to bulimia.
Effects of bulimia
As aforementioned, bulimia can significantly impact a sufferer's physical and mental health. Symptoms of bulimia range from changes in appearance to physical problems, such as aches and pains and severe dehydration as a result of constant purging. There are however more severe effects of bulimia that can occur if the illness is not treated. In particular, vomiting and use of laxatives can lead to low potassium levels in the body, which can trigger a wide range of negative side effects.
Some of the more severe effects of bulimia are:
- kidney failure
- chronic irregular bowel movements
- heart problems or irregular heartbeat
- tooth and gum problems
- inflammation of the oesophagus as a result of forced vomiting
- ruptured stomach
- acid reflux or ulcers
- chronic constipation due to laxative abuse
- sore throat and hoarseness
- problems in pregnancy
- swelling of the hands and feet
Treatment for bulimia
Like the majority of illnesses, the longer an individual suffers from bulimia, the worse it becomes. This is why it is important to try and detect bulimia as soon as possible, and seek help immediately if concerns arise. Recognising that you have the condition is the first crucial step in builima treatment. It is possible to recover from the illness, but it can be a long and difficult process, so sufferers will need to have a genuine desire to get better.
Bulimia treatment usually involves a team of medical doctors, dietitians and mental health experts such as a counsellor who provide a support network for sufferers. There are counsellors who specialise in eating disorders, and provide a vital source of comfort for sufferers - helping them to open up about their problems and identifying any psychological reasons for their unnatural eating habits. Sessions usually involve cognitive behavioural therapy techniques, which are designed to help clients change their attitudes to food and weight, whilst teaching them to deal more effectively with emotional issues.
Whilst psychological treatments help sufferers to re-establish healthy attitudes towards eating, medication such as antidepressants will be prescribed to help alleviate some of the psychological problems that are associated with bulimia. Ultimately it has been found that the most successful treatment for bulimia nervosa is a mixture of medication, family therapy, patient education and behavioural therapy.
What should I be looking for in a counsellor or psychotherapist?
As it stands there is no law stipulating a required level of training for counsellors treating individuals with bulimia nervosa. However, the National Institute for Health and Care Excellence have developed a set of clinical guidelines that issue advise on types of psychological treatment, medication and available services.
Key recommendations include the following:
- Cognitive behaviour therapy for bulimia nervosa (CBT-BN), a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months.
- Adolescents with bulimia nervosa may be treated with CBT-BN, adapted as needed to suit their age, circumstances and level of development, and including the family as appropriate.
- When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered.
- Interpersonal psychotherapy should be considered as an alternative to CBT, but patients should be informed it takes 8–12 months to achieve results comparable with cognitive behaviour therapy.
For more information, please visit the full NICE guidelines:
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What our experts say
- What are CBT-BN, CBT-BED and CBT-E?
National CBT-E for Eating Problems & Disorders8th August, 2013
- When the sun breaks down - Eating Disorders and the issue of control
Gregory Szanto, MA(Oxon), Dip.Counselling, Dip.Eating Disorders, MBACP31st May, 2012
- Compulsive Eating and Bulimia Nervosa
Ian Beardsall (MBACP, MBPA, CCC)9th April, 2008
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