Everything You Should Know About Bulimia Nervosa

Bulimia nervosa is a deeply complex eating disorder with a vast spectrum of highly distressing symptoms. The illness is predominantly characterized by bingeing (via American Family Physician). For some people, this might involve a vicious binge-purge cycle, and for others it could include excessive exercise or laxative abuse. 

It's estimated that around 9% of Americans will experience an eating disorder at some point in their lives, per the National Association of Anorexia Nervosa and Associated Disorders. Bulimia, like most eating disorders, is more commonly reported by women, although rates appear to be increasing among men in recent years (via American Family Physician). The truth is, being an incredibly secretive disorder — imbued by a great deal of embarrassment and shame — it can be difficult to determine precisely who is affected by the condition (via Eating Disorders). People often live with the condition for years, but it can have significant health consequences if left untreated.

Much remains to be understood about the etiology and treatment of bulimia nervosa, point out researchers (via New Insights into the Prevention and Treatment of Bulimia Nervosa). Read on to get a better understanding of this relatively understudied psychiatric illness.

What does bulimia look like?

Bulimia nervosa has a wide range of physical, emotional, and behavioral characteristics (via American Family Physician). Recurrent and distressing binge-eating is the main hallmark of the illness. People with the condition usually fluctuate between consuming large amounts of food and taking steps to either get rid of what they've eaten or avoid the effects of bingeing such as weight gain or overwhelming emotions. This often means chronic induced vomiting, but it can also involve excessively exercising and fasting.

People with bulimia have an abnormal preoccupation with food and eating, according to the DSM-5 diagnostic criteria (via ANAD). Common behaviors may include dieting, obsessively thinking about food, and engaging in ritualistic eating patterns such as eating in isolation, hiding or hoarding food, and only eating at certain times or in specific ways. In order for a diagnosis to be made, these dysfunctional behaviors must occur, on average, at least once a week for three months.

There are different subtypes of bulimia

When people think of bulimia, the symptom that generally comes to mind first is purging. While it's true that many people with bulimia make themselves vomit, the illness isn't necessarily defined by this behavior, notes a study from the Journal of Cognitive Psychotherapy. Bulimia essentially involves the compulsion to compensate for a large amount of food or the number of calories an individual has consumed in a brief period of time. This may be driven by a fear of weight gain. But it can also stem from the need to relieve the negative emotions that are built up or triggered by overeating.

Most commonly, compensatory behaviors involve self-induced vomiting. It can also entail excessive exercising, fasting, misusing diet pills, or taking laxatives or diuretics, as stated by the University of Pittsburgh Medical Center. People with bulimia usually experience a sense of being out of control around food. Some studies even liken bulimia to a drug addiction (via Journal of Clinical Psychopharmacology). For some, the cycle of bingeing and purging can feel addictive and difficult to break free from, and food cravings can feel overpowering and exhausting.

Dieting and body image issues are significant risk factors

Excessive and constant thoughts about body weight and shape are a key part of the diagnostic criteria for bulimia, note researchers (via New Insights into the Prevention and Treatment of Bulimia Nervosa). People grappling with the illness often score low on measures of self-esteem and body dissatisfaction. They tend to go to huge lengths to shed weight or avoid putting it on, and may hide their body in baggy clothes or repeatedly check their reflection in the mirror for flaws. At the same time, studies show that dietary restriction and restraint often exacerbate the symptoms associated with bulimia (via International Journal of Environmental Research and Public Health).

There's strong evidence that the internalization and pursuit of the thin ideal are prominent causal risk factors for the disorder (via Annual Reviews). This encompasses the belief that being thin is necessarily equal to attractiveness as well as perceived societal pressure to be thin. But while many individuals struggling with the disorder tend to derive their self-worth from their body weight and shape, not everyone with bulimia has a problematic body image. It goes without saying that bulimia manifests in a wide variety of ways, like most other mental illnesses.

People with bulimia are usually a normal body weight

There's a common misconception that people with eating disorders are typically ultra-thin. But in truth, it's not always possible to tell that someone has an eating disorder just by looking at them, point out researchers (via the International Journal of Eating Disorders). In fact, most people with bulimia are a normal weight: Based on the findings of a study from the journal Biological Psychiatry, around 65% of people with the illness have a "normal" body mass index, and only 3.5% are underweight. It's also not uncommon for bulimic patients to be overweight, according to research published in the journal Eating and Weight Disorders.

People with bulimia may experience episodes of food restriction which can lead to weight loss. However, they also tend to consume more calories overall through binge-eating, which causes them to retain a normal body weight or to put on weight (via Eating and Weight Disorders). This can be deceptive in that a person might look healthy from the outside, but behind closed doors, they're suffering emotionally and mentally and engaging in dysfunctional and potentially dangerous behaviors like purging. Research shows that the stereotypes that people hold around eating disorders often prevent people from seeking help and getting the support that they need (via International Journal of Eating Disorders). It's common for sufferers to go for years without receiving a diagnosis or undergoing treatment.

There's no one single cause

Bulimia, just like any other eating disorder, is multifactorial. There are many different elements that may underlie the condition, including genetic, neurochemical, environmental, sociocultural, and psychological factors, according to a 2021 study from the Journal of Eating Disorders. It's suggested that individuals with certain personality traits and psychological tendencies are more likely to develop bulimia, such as those with high levels of impulsivity and increased sensation-seeking behavior. These traits may signify differences in brain function that put people at special risk of food-related mental illness. 

Studies have identified a link between bulimia and interpersonal trauma (via the International Journal of Eating Disorders). Eating disorders are generally much higher in people with post-traumatic stress disorder (PTSD), and approximately one-third of women with bulimia also meet the criteria for PTSD. People struggling with bulimia are also more likely to have relatives with a history of eating disorders, which indicates that there may be a familial predisposition to its development (via Behavioral Sciences). 

Other potential contributing factors are said to include the early onset of puberty, nutritional difficulties during childhood, and an impaired ability to respond to internal bodily sensations like hunger and satiety, per the Journal of Eating Disorders. Scientists and clinicians can't pinpoint exactly what gives rise to bulimia or predict precisely who will develop it. But most experts agree that eating disorders are likely to be rooted in a complex interaction of numerous factors rather than one single cause (via Journal of Integrated Social Sciences).

Certain brain regions may contribute to binge eating

There's a lot to be answered when it comes to the neurobiology behind bulimia. But many scientists claim that eating disorders may not be solely driven by culture and environment — and that the brain is also part of the problem. 

The dopamine reward system seems to be altered in people with bulimia, according to a study published in the journal CNS Spectrums. Dopamine is the neurotransmitter that motivates us to act, either to seek pleasurable experiences or to avoid negative ones. Bulimic women, specifically, were found to have a hyporesponsive reward circuitry. This is a weaker-than-normal brain response that prevents an individual from devaluing food after they've eaten enough of it, which is what causes them to binge.

A 2022 study discovered that people with bulimia have impaired medial and lateral prefrontal cortices, which are the parts of the brain that moderate emotions, cravings, and eating behaviors. This deficiency may contribute to the feeling of being out of control around food, leading to uncontrollable binge-eating episodes.

Who is affected by bulimia?

Bulimia can afflict people of all ages, races, sexual orientations, and walks of life (via American Addiction Centers). A large number of people with bulimia don't receive help until they're in their thirties, reports Johns Hopkins Medicine. And by this point, they may have been struggling with highly distressing symptoms for more than a decade. The lifetime risk of bulimia is said to be around 1.5% for women and 0.5% for men in the U.S (via American Addiction Centers). Most experts agree that the rates among males tend to be underestimated due to the prevailing stereotype of eating disorders as a female issue (via the American Journal of Men's Health). This can create reluctance among many men with bulimia to admit that they have a problem.

People of color and from ethnic minority backgrounds are significantly more likely to face bulimia than their white peers, according to the National Eating Disorders Association. However, the stigma associated with bulimia means that people from marginalized demographics often go undiagnosed and slip between the cracks of healthcare.

Research has shown that while bulimia typically peaks in late adolescence, it can start at any age, including both childhood and adulthood (via Journal of Eating Disorders). Often, people with bulimia don't receive help until they've already been struggling for many years, since the illness is easier to hide than some other eating disorders like anorexia and can go under the radar. But symptoms tend to worsen over time if left untreated.

The consequences can be life-threatening

A common myth is that bulimia isn't as serious as anorexia. This often stems from the fact that people struggling with the disorder don't necessarily look unwell or visibly thin, explains the National Eating Disorders Association. But the binge-purge cycle that's characteristic of bulimia can have a number of harmful and long-term effects on both physical and mental health. 

Frequent self-induced vomiting can damage the throat, mouth, and digestive tract (via the International Journal of Eating Disorders). The gastric acid in vomit can erode the enamel on your teeth and turn them brown or yellow, or in more extreme cases, cause them to fall out. The force and pressure of purging can irritate the esophagus and cause the rupture of the gastric artery. Many bulimic patients experience gastrointestinal and digestive problems like acid reflux, abdominal pain, irritable bowel syndrome, and bloating.

The secrecy that accompanies bulimia can take a huge toll on an individual's mental health and emotional wellbeing (via the Univesity of Rochester Medicine). Various psychological and emotional difficulties tend to accompany bulimia and precede the onset of bulimic symptoms, including anxiety, depression, low self-esteem, and feelings of inadequacy, according to the Journal of Eating Disorders. The illness can also cause nutritional deficiencies that lead to irritability and mood problems, and the constant monitoring of weight and food can perpetuate obsessive thoughts and behaviors over time. Research shows that people with bulimia have a 3.9% higher-than-normal mortality rate (via the American Journal of Psychiatry).

What does effective treatment for bulimia look like?

It's estimated that only one in ten people with bulimia actually receive treatment (via the American Journal of Psychiatry). But early intervention is key for effective and sustainable recovery. Starting treatment early can mean interrupting the progression of the illness before it weeds its way into various areas of life, notes a 2021 study from the Journal of Eating Disorders.

Full recovery from bulimia is entirely possible, but there are many different pathways to treatment. Family-based therapy (FBT), sometimes referred to as the Maudsley Approach or Maudsley Method, is typically used to treat adolescents and young people with bulimia in outpatient settings (via Clinical Therapeutics). Individual psychotherapy is a popular treatment for adults.

Cognitive-behavioral therapy (CBT) is widely regarded as the gold standard of treatment for bulimia (via Frontiers in Psychology). It can help people modify their disordered behaviors (such as bingeing and purging) and alter some of the dysfunctional beliefs, attitudes, and cognitive processes that underlie the illness. But despite its sturdy evidence base and widespread use, studies have shown that CBT isn't effective for everyone, especially individuals with comorbid personality disorders.

A positive self-image can help with recovery

Self-image is the subjective way in which we view ourselves. It can also be understood as "the way a person treats him- or herself", explain researchers (via the Journal of Eating Disorders). A poor self-image can contribute to the development of bulimia. Equally, an improved self-image plays an important role in recovery: Increasing levels of self-love and lowering self-blame and self-judgment have been found to optimize the chances of successful outcomes in eating disorder recovery.

Body image concerns can persist even after a person has undergone treatment for bulimia. It tends to be one of the most common lingering symptoms of an eating disorder, according to researchers (via Eating Disorders Review). An "increased malleability of the bodily self" is a common trait among people with eating disorders, notes a study published in the International Journal of Eating Disorders.

Once again, cognitive-behavioral interventions have been shown to be the most effective approaches to addressing body dissatisfaction (via the Journal of Eating Disorder). But there's no one-size-fits-all approach when it comes to treating body image issues or eating disorders — just as the illness unfolds in various ways, recovery is ultimately an individualized process that will look different for different people.