Bulimia (Bulimia nervosa) - An often unrecognized but serious eating disorder
Bulimia nervosa is a psychosomatic eating disorder. The disease is characterized above all by repeated, uncontrolled cravings or eating attacks, which are usually followed by self-induced vomiting or the misuse of laxatives and emetics. This is also the basis for the well-known name “eating vomiting”. Together with anorexia nervosa and binge eating disorder, bulimia is one of the best known and most common forms of severe eating disorders. But bulimia is often not recognized at an early stage, since the sufferers are often of normal weight and the disease hardly appears on the outside. Despite a high level of suffering, many sufferers are hiding their disturbed eating behavior and serious health problems arise as a result of bulimia nervosa. The possible causes of this mental illness are diverse.
Definition of eating sickness
The term bulimia is derived from the Greek words "bous" and "limos" and is often translated as "ox hunger". For a long time, so-called eating vomiting was considered a variant of anorexia until bulimia was defined and recognized as an independent disease in the 1980s. In contrast to other psychological eating disorders, which are usually associated with being under or overweight, bulimia nervosa is a disease that is hardly visible to outsiders, especially in the early stages. Affected people are usually of normal weight and often act confidently on others and usually show a controlled or normal eating behavior in public. The disease takes place in stealth.
A vicious cycle of binge eating and its compensation
The uncontrolled bouts of eating (“eating attacks”) that characterize bulimia occur repeatedly but with different frequencies and vary from several times a day to a few times a week. The calorie intake for a single binge can be up to 10,000 calories. There are basically two different types of bulimia. If the sick vomit after the food cravings or are removed, this is called the "purging type". Since this is the most common variant, the term eating vomiting is generally used. The "non-purging type" is a bulimic eating disorder in which vomiting is absent and measures such as starvation or excessive exercise lead to weight control.
Bulimia is often preceded by anorexia
Many features of bulimia nervosa are similar to those of anorexia nervosa, including the underlying body schema disorder and thus a wrong perception of your own body and an excessive concern about body shape and weight. It is not uncommon to find that anorexia already existed before the diagnosis of bulimia. If some of the central diagnostic criteria are missing in the clinical picture, such as a body structure disorder, or if there are only insignificant effects on body weight, we speak of atypical bulimia nervosa.
The central features of bulimia are repeated and uncontrolled bouts of eating, in which an unusually large amount of mostly fat and carbohydrate-rich food is consumed in a mostly short period of time, compared to most people. Sufferers cannot stop eating during such a cravings attack and sweets in particular have a triggering function. After these “eating attacks”, those affected feel a great fear of gaining weight or are ashamed of losing control of their own, so that there is a need to reverse the amount of food and calories consumed. The self-esteem of those affected is extremely dependent on body weight or body shape. A balance to the binge eating is then attempted through self-induced vomiting, taking laxative and drainage medication, periods of fasting or even excessive sports. These symptoms describe the typical vicious cycle of bulimia nervosa.
Large fluctuations in weight in a short period of time can be typical signs of bulimia, but most of those affected have normal weight or light underweight and are more likely to suffer from the symptoms of malnutrition with an impaired vitamin and electrolyte balance. Calluses on the fingers (Russell sign) are an early warning signal. These occur with frequent self-induced vomiting due to the contact of knuckles and incisors.
In addition to the typical body structure disorder, which is accompanied by a problem of self-esteem (despite normal weight, people with bulimia nervosa feel too fat), eating addiction is often accompanied by other mental disorders such as anxiety or compulsion. Some of those affected suffer from listlessness, depression or self-hatred and think of suicide.
The various physical consequences of bulimia nervosa are similar to those of anorexia nervosa, but in particular the vomiting typical of bulimia and the previous binge eating can cause serious damage. Repeated vomiting and the associated excessive presence of stomach acid in the mouth causes tooth damage, such as the loss of tooth enamel and tooth substance or tooth decay. Salivary glands also frequently swell and catch fire. In some patients, the swellings of the salivary glands become externally visible through so-called "hamster cheeks". A soft tissue thickening of finger and toe limbs can also be noticed (so-called drumstick fingers).
Hoarseness, sore throat, and inflammation of the esophagus (esophagitis), the pancreas (pancreatitis) and the gastric mucosa (gastritis) are common follow-up symptoms. The consumption of enormous amounts of food in a very short time can lead to an acute stomach enlargement and sometimes even stomach tears.
Poor nutrition, like anorexia nervosa, can lead to hormonal changes that trigger menstrual disorders in many women and can also result in infertility. Dry skin and hair loss are also often reported in connection with an altered thyroid hormone balance. In addition to diarrhea, permanent abuse of laxatives often also results in edema. If the symptoms of the disease lead to a massive disturbance in the electrolyte balance and, in particular, to a potassium deficiency (hypokalaemia), bulimia can become life-threatening due to cardiac arrhythmia and kidney damage.
Morphological changes in the brain (brain atrophy or pseudoatrophy) were observed in about half of those affected. In contrast to anorexia nervosa with bulimia nervosa, the increased risk of osteoporosis after a long illness is probably not present.
Causes - A combination of many factors
Like the symptoms, the causes of bulimia are similar in many ways to those of anorexia. It is not uncommon for phases of anorexia and bulimia to alternate, or the disease of bulimia nervosa was preceded by anorexia nervosa.
Various and individually different factors play a role in the development of the disease, which means that it is usually not easy to clearly identify the respective causes. Mostly it is a combination of personal and psychological factors together with social and biological components.
Typical and frequent personal components include, in particular, impaired body awareness and self-esteem problems. Sick people make themselves and their self-esteem dependent on body weight and figure. Being slim is the top priority in order to feel good, whereby the personal perception of one's own body shape is distorted.
What role do family and society play?
Sometimes an eating disorder is preceded by a stressful event, such as personal and family blows of fate. Abuse and abuse can also play a role. In addition to problems in the social and family environment (e.g. conflicts, pressure to perform), social constraints and expectations are often decisive. Common reasons for this are bullying and the general slimming craze of the western world. Girls and young women in puberty, in particular, are often insecure about their bodies and, in combination with certain personality traits (e.g. great stamina), are very susceptible to this.
In addition to the eating disorder, there is often an abuse of psychoactive substances, which is particularly common in bulimia as an alcohol problem. Substance addiction is also observed more often in the family of those affected. Various studies have found family clusters of eating and obsessive-compulsive disorder as well as depression. Bulimia is therefore also associated with a certain genetic disposition.
The described signs of bulimia often remain hidden. In contrast to anorexia, the bulimic disorder does not go hand in hand with continuous weight loss, rather overweight and underweight alternate (in the case of anorectic episodes). Those affected mostly successfully keep their eating disorder secret or deny it vehemently, because they are ashamed and suffer from great feelings of guilt. The disease therefore typically remains unnoticed for a long time.
Eating disorders are complex and not always obvious?
If you suspect an eating disorder, it is not so easy to differentiate between the various forms and make a clear diagnosis due to the diverse and similar symptoms and causes. Mixed forms can also always occur. Bulimia nervosa is particularly difficult to differentiate from the so-called “binge eating” eating disorder, which is also characterized by episodes of binge eating with loss of control. However, there is no compensation due to vomiting or other measures and therefore overweight occurs more often.
Indications of bulimic behavior can be, for example, the (suddenly) regular visit to the toilet shortly after eating as well as injuries with denture prints on the fingers and back of the hand. The most important diagnostic criteria are the following:
- Persistent preoccupation with food and a recurrent greed for food that leads to the typical binge eating (at least two a week for three months or more),
- Try to reverse the uncontrolled food intake, mostly through self-induced vomiting,
- Pathological fear of becoming fat and a distorted perception of your own body weight.
For a thorough diagnosis, it is important that those affected seek special medical and psychotherapeutic advice. In addition to an in-depth physical examination, detailed and structured discussions provide decisive information about the present form of an eating disorder and its treatment options. The interviews often consist of predetermined interview questionnaires. When making a diagnosis, it is important that in addition to the eating disorder, any accompanying mental disorders or illnesses are also identified and can therefore be taken into account in a therapy plan. Since sufferers often have difficulty acknowledging their illness, it is often close confidants from the family and friends who first detect signs of an eating disorder. These people are encouraged to talk to those affected in the most sensitive way possible and to seek professional help.
Around one to two out of 100 people develop bulimia during their lifetime. However, individual symptoms appear far more frequently and an overall high number of unreported cases is suspected. Around 90% of women and young girls are affected, although eating disorders are becoming increasingly common among young men.
As with all eating disorders, the basic prerequisite for successful treatment is the personal attitude of those affected. In addition to recognizing and accepting one's own illness, there must also be the will and motivation to overcome it. If this is the case and there is a clear diagnosis, outpatient therapy usually takes place. In the case of strikingly severe symptoms with physical consequences or self-harming behavior, the inpatient may also need to stay in hospital. Successful treatment often consists of a combination of different therapeutic approaches. The aim of the treatment is to break the vicious cycle of food cravings and vomiting and to normalize eating behavior. Basically, various approaches from physical rehabilitation and nutritional advice as well as individually tailored psychotherapy (including family involvement) are combined.
Typically, sick people deal with the subject of food a lot and in depth, but there is little in-depth knowledge about a healthy diet. Education and advice on a balanced and healthy diet can lead to a significant improvement in pathological behavior. Often a meal plan and offering previously avoided dishes help to regulate the disordered eating behavior again.
Family and other victims can help
Different concepts are used in psychotherapeutic treatment. Common forms of therapy include cognitive behavior therapy, interpersonal therapy or psychodynamic approaches. Among other things, these treatments are intended to increase self-confidence and to allow patients to deal personally with their eating disorder in order to bring about changes in behavior. Family involvement can be very important, especially for young people. The main aim is to give the family an important role in overcoming the eating disorder. Group therapies and self-help groups are also repeatedly successful in treating bulimia.
Antidepressants are usually only integrated into the treatment if there is also a depressive mood or if psychotherapy does not bring about the desired improvement. Regardless of whether you have depression, therapy with selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, can help those affected. If the sufferers already suffer from physical follow-up symptoms, such as underweight or malnutrition, besides psychotherapeutic treatment, the primary goal is to treat them and prevent further physical damage.
The chances of success of a treatment depend in particular on the severity and duration of the illness. In general, the chances of a cure for bulimia are better than for anorexia and the risk of death is also lower. Statistically, 50 to 75 percent of sufferers are cured of bulimia, although a shift in symptoms or the relapse rate are not taken into account.
In the case of a serious eating disorder, such as eating vomiting, medical and psychotherapeutic treatment is absolutely necessary. Naturopathy can accompany and support conventional medical treatment for bulimia nervosa. Mostly, naturopathic measures are only used in the initial stages or if the symptoms are rather mild. Homeopathic therapies and acupuncture are the most common accompanying measures. In the early phase of bulimia, Schuessler salts are sometimes used to try to balance psychological causes.
Current state of research
Eating disorders such as bulimia nervosa are serious and life-threatening diseases that often begin during or even before puberty and often affect those affected for a very long time. Nevertheless, a recent long-term study published in the Journal of Clinical Psychiatry seems more likely than previously thought that adults will be cured and recover from their eating disorder. This should encourage everyone affected and motivate them to fight their illness. (jvs, cs; updated on July 11th, 2018)
This may also be of interest: vomiting blood (hematemesis)
Eating disorders: anorexia nervosa (anorexia)
Depression (depressive syndrome)
Author and source information
This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
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ICD codes for this disease: F50ICD codes are internationally valid encodings for medical diagnoses. You can find e.g. in doctor's letters or on disability certificates.