>> Bulimia Nervosa
People with bulimia are extremely concerned
with their weight, yet they can’t fight the
compulsion to binge. So they drastically overeat,
and then they purge, fast, or exercise to get rid
of the calories. This vicious cycle of bingeing and
purging takes a toll on the body, and it’s even
harder on emotional well-being. But the cycle can
be broken. Effective bulimia treatment and support
can help you or a loved one develop a healthier relationship
with food and overcome feelings of anxiety, guilt,
WHAT IS BULIMIA NERVOSA?
Bulimia nervosa is characterized by frequent episodes
of binge eating, from twice a week to multiple times
a day, followed by frantic efforts to avoid gaining
During an average binge, a bulimic consumes 3,000 to
5,000 calories in one short hour. After it ends, the
person turns to drastic measures to “undo”
the binge, such as taking ex-lax, inducing vomiting,
or going for a ten-mile run.
The key features of bulimia nervosa are:
- Regular episodes of out-of-control binge
- Inappropriate behavior to prevent weight
- Self-worth is excessively influenced by
weight and physical appearance
There are two types of bulimia, distinguished by the
methods the bulimic uses to compensate for the binge
eating. In the purging type
people physically purge the food from the body by
throwing up or using laxatives, enemas, or diuretics.
In the nonpurging type
is much less common—bulimics make up for their
lack of restraint by fasting, exercising to excess,
or going on crash diets.
Women are much more likely than men to develop bulimia;
approximately 90% of those with the disorder are female.
Younger women are particularly at risk. Bulimia typically
begins during the late teens or early twenties, often
following a strict period of dieting or a stressful
THE BINGE AND PURGE CYCLE
I HAVE BULIMIA?
the following questions. The more “yes”
answers, the more likely you’re suffering
from Bulimia or another eating disorder.
- Are you obsessed with your body and your
- Does food and dieting dominate your life?
- Are you afraid that when you start eating,
you won’t be able to stop?
- Do you ever eat until you feel sick?
- Do you ever feel guilty, ashamed, or depressed
after you eat?
- Do you ever vomit or take laxatives to
control your weight?
Bulimia’s destructive cycle of bingeing and purging
is triggered by dieting. Driven by a desire to be thin,
people with bulimia go on strict diets. But the more
rigid and restrictive the diet plan, the more preoccupied
they become with food. They obsess over what, when,
and how much to eat, what they shouldn’t eat,
and how to avoid eating. At the same time, their calorie
restriction triggers physical cravings—the body’s
way of asking for the nutrition it needs
As the tension, hunger, and feelings of deprivation
build, the compulsion to eat becomes too powerful to
resist: a “forbidden” food is eaten; a dietary
rule is broken. In the all-or-nothing mindset of bulimics,
any slip-up is a total failure. They’ve already
blown it, so they might as well let go and enjoy an
all-out binge. But the enjoyment of a bingeing is soon
replaced with feelings of guilt, revulsion, and self-loathing.
In an effort to regain control and make up for the excess
calories eaten, most bulimics purge to make up for their
bingeing. While purging is intended to counteract binge
eating, it ends up reinforcing it. It’s harder
to say no to temptation when you think you can avoid
the consequences. “This is the last time,”
people with bulimia tell themselves as they launch into
a new diet. In the back of their minds, however, they
know that they can always throw up, pop a water pill,
or use laxatives if they lose control again. What they
don’t realize is that purging doesn’t come
close to wiping the slate clean after a binge.
Purging does NOT prevent weight gain
Contrary to popular belief, purging isn’t very
effective at getting rid of calories, which is why most
bulimics end up gaining weight over time. Vomiting immediately
after eating will only eliminate 50% of the calories
consumed at best—and usually much less. This is
because calorie absorption begins the moment you put
food in the mouth. Laxatives and diuretics are even
less effective. Laxatives get rid of only 10% of the
calories eaten, and diuretics do nothing at all. You
may weigh less after taking them, but that lower number
on the scale is due to water loss, not true weight loss.
SIGNS AND SYMPTOMS OF BULIMIA
People who have bulimia usually try to hide their bingeing
and purging. They’re ashamed over their inability
to control themselves, so they binge when others aren’t
around. If they clean out the fridge, they’ll
replace the food so others in the house won’t
notice how much they’ve eaten. If they’re
buying food for a binge, they’ll go to four separate
markets so the checker won’t suspect what they’re
up to. They’ll gorge late at night or behind locked
doors—anything to conceal their eating habits.
But despite the secrecy, there are warning signs and
symptoms of bulimia that can alert you to the problem.
Despite the fear bulimics have of becoming fat, being
underweight is not a characteristic warning sign of
bulimia. In fact, people with bulimia are usually
of normal weight or are even overweight. If a person
binges and purges but is dramatically underweight,
he or she most likely suffers from the purging type
of anorexia, rather than bulimia.
Binge eating signs and symptoms
Purging signs and symptoms
- Lack of control over eating.
Inability to stop eating. Eating until the
point of physical discomfort and pain.
- Secrecy surrounding eating.
Going to the kitchen after everyone else
has gone to bed. Going out alone on unexpected
food runs. Wanting to eat in privacy.
- Eating unusually large amounts
of food with no obvious change
- Disappearance of food,
numerous empty wrappers or food containers
in the garbage, or hidden stashes of junk
- Alternating between overeating
and fasting. Rarely eats normal
meals. It’s all-or-nothing when it
comes to eating.
Physical signs and symptoms of bulimia
- Going to the bathroom after meals
– Frequently disappears after meals
or takes a trip to the bathroom to throw
up. May run the water to disguise sounds
- Using laxatives, diuretics, or
enemas after eating. May also take
diet pills to curb appetite or use the sauna
to “sweat out” water weight.
- Smell of vomit. The bathroom
or the person may smell like vomit. They
may try to cover up the smell with mouthwash,
perfume, air freshener, gum, or mints.
- Excessive exercising
– Works out strenuously, especially
after eating. Typical activities include
high-intensity calorie burners such as running
EFFECTS OF BULIMIA
- Calluses or scars on the knuckles
or hands from sticking fingers
down the throat to induce vomiting.
- Puffy “chipmunk” cheeks
caused by repeated vomiting.
- Discolored teeth from
exposure to stomach acid when throwing up.
May look yellow, ragged, or clear.
- Frequent fluctuations in weight
- Weight may fluctuate by 10 pounds or more
due to alternating episodes of bingeing
Chronic bingeing and purging leads to many health
problems—some of them life-threatening. The
most dangerous side effect of bulimia is dehydration
due to purging. Vomiting, laxatives, and diuretics
can cause electrolyte imbalances in the body, most
commonly in the form of low potassium levels. Low
potassium levels trigger a wide range of symptoms
ranging from lethargy and cloudy thinking to irregular
heartbeat and death. Chronically-low levels of potassium
can also result in kidney failure.
Other common medical complications and adverse effects
of bulimia include:
BULIMIA CAUSES AND RISK FACTORS
- Weight gain
- Abdominal pain, bloating
- Swelling of the hands and feet
- Chronic sore throat, hoarseness
- Broken blood vessels in the eyes
- Swollen cheeks and salivary glands
- Weakness and dizziness
- Tooth decay and mouth sores
- Acid reflux or ulcers
- Ruptured stomach or esophagus
- Loss of menstrual periods
- Chronic constipation from laxative abuse
There is no single cause of bulimia. While low self-esteem
and concerns about weight and body image play major
roles, there are many other contributing causes, including
social, psychological, and biological factors.
Major causes and risk factors for bulimia include:
TREATMENT AND RECOVERY
- Poor body image –
Our culture’s emphasis on thinness
and beauty can lead to body dissatisfaction,
particularly in young women bombarded with
media images of an unrealistic physical
- Low self-esteem –
People who think of themselves as useless,
worthless, and unattractive are at risk
for bulimia. Things that can contribute
to low self-esteem include depression, perfectionism,
childhood abuse, and a critical home environment.
- Dieting – People
who diet are much more likely to develop
an eating disorder than those who don’t.
The deprivation of drastic dieting can trigger
binge eating, leading to bulimia’s
- Appearance-oriented professions
or activities – People who
face tremendous pressure to look a certain
way or stay thin are vulnerable to developing
an eating disorder. Those at risk include
ballet dancers, models, gymnasts, wrestlers,
runners, and actors.
- Major life changes –
Bulimia is often triggered by stressful
changes or transitions, such as the physical
changes of puberty, going away to college,
or the breakup of a relationship. Bingeing
and purging may be a misguided attempt to
cope with the stress.
- Biological factors –
Eating disorders run in families, indicating
a genetic component. Research also shows
that low levels of serotonin play a role
Regardless of how long you’ve had bulimia, you
can get better. With treatment and support, many bulimics
experience a full and successful recovery. To stop
the cycle of bingeing and purging, it’s important
to seek professional help early, follow through with
treatment, and resolve the underlying emotional issues
that caused the bulimia in the first place. While
recovering from an eating disorder isn’t easy,
regaining your health and happiness is worth the effort.
Therapy for bulimia
Because poor body image and low self-esteem underlie
bulimia, psychotherapy is an important aspect of treatment.
Many people with bulimia feel isolated and shamed
by their bingeing and purging, and therapists can
help with these feelings.
The treatment of choice for bulimia is cognitive-behavioral
therapy. Cognitive-behavioral therapy targets the
unhealthy eating behaviors of bulimia and the unrealistic,
negative thoughts that fuel them. Cognitive-behavioral
therapy for bulimia involves two phases:
importance of deciding not to diet
- Breaking the binge-and-purge
cycle – The first phase of
bulimia treatment focuses on stopping the
vicious cycle of bingeing and purging and
restoring normal eating patterns. Patients
learn to monitor their eating habits, avoid
situations that trigger a desire to binge,
cope with stress in ways that don’t
involve food, eat regularly to reduce food
cravings, and fight the urge to purge.
- Changing unhealthy thoughts and
patterns – The second phase
of bulimia treatment focuses on identifying
and changing dysfunctional beliefs about
weight, dieting, and body shape. Patients
challenge their “all-or-nothing”
attitudes about eating, explore the connection
between emotions and eating, and rethink
the idea that self-worth is based on weight.
Treatment for bulimia is much more likely to succeed
when people stop dieting. When bulimics stop trying
to restrict calories and follow strict dietary rules,
they are no longer overwhelmed with cravings and thoughts
of foods. By eating normally, they can break the binge-and-purge
cycle and still reach a healthy, attractive weight.
In addition to cognitive-behavioral therapy, there
are several other bulimia treatments that are effective.
Interpersonal psychotherapy helps people with bulimia
solve relationship issues and interpersonal problems
that are contributing to their eating disorder. Interpersonal
psychotherapy also treats the depression and low self-esteem
that goes along with bulimia. Group therapy is also
helpful in bulimia treatment. Group therapy for bulimia
involves education about the eating disorder and strategies
for overcoming it. It can also help bulimics feel
less alone in their suffering.
Antidepressant medications for bulimia
Antidepressants are often used in the treatment of
bulimia. When combined with therapy, antidepressant
medications can help reduce binge eating. They can
also improve preoccupation with weight and body image,
as well as the depression that often accompanies bulimia.
Make sure to consult a physician before beginning
HELPING A PERSON WITH BULIMIA
If you suspect that your friend or family member has
bulimia, talk to the person about your concerns. Your
loved one may deny bingeing and purging, but there’s
a chance that he or she will welcome the opportunity
to open up about the struggle. Either way, bulimia
should never be ignored. The person’s physical
and emotional health is at stake.
WHAT YOU CAN DO FOR SOMEONE
You can’t force a person with an eating disorder
to change and you can’t do the work of recovery
for them. But you can help by offering your compassion,
encouragement, and support throughout the treatment
Someone with an Eating Disorder
Suzanne Barston, Melinda Smith, M.A., and Jeanne Segal,
Ph.D., contributed to this article. Last modified
Reprinted with permission from http://www.helpguide.org/
C 2008 Helpguide.org. All rights reserved.
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