What is Bulimia?

From my experience with clients, and from studying and training to be an eating disorder recovery coach, restriction is behind almost every type of eating disorder. With anorexia, the restriction is very clear, even though the person with the disorder might not see it so clearly. When it comes to bulimia, or anorexia binge-purge sub-type, the client keeps wanting to go back to restriction, to control the binges as a way of stopping the purging behaviors. However, recovery can only start once it becomes clear that the start of the chain reaction is the restriction and not the binging, even if the restriction is just mental. 

I’ve helped clients who binge and purge many times a day, clients who binge and purge on the weekend only after a big meal, and clients who purge no matter what they’ve eaten, even if a relatively small amount. I’ve even had a random person tell me she purges after a big meal thinking it’s perfectly normal behavior. If the behavior has become a habit, and is repeated consistently, then it is considered a serious disorder that will have dire consequences on the person’s mental and physical health. 

“Today is the worst day ever. I’m not happy with myself at all…I’m starting to fear feeling empty and lonely, and I’m afraid of hunger, I’m afraid of everything and I’m stressed because of that, I took my anger out on myself…I eat large meals and vomit. Actually, from noon to night, I just eat and vomit, then eat again and vomit…Sometimes I eat sweets, other times sandwiches, and at times fruits…I eat anything in front of me and vomit. I’m so disgusted with myself and I feel like I’m not satisfied, I want to eat more…I feel like I’ve lost control of myself…but I’m responding to my negative thoughts and giving in to them…After the third time of vomiting, I sat down and cried…I hated everything and I’m still scared,  I don’t know how to cope with myself and I feel hopeless.” 

A client with anorexia binge-purge sub-type, 21yrs 

Bulimia is an eating disorder characterized by episodes of overeating followed by efforts to get rid of the food because of the fear of weight gain. A person may go through this cycle repeatedly, leaving them physically and mentally exhausted.

While bulimia might seem “less severe” than anorexia, it still has serious effects on both physical and mental health.

Diagnosis

The diagnosis of bulimia nervosa is based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which include:

1. Frequent Episodes of Binge Eating: Eating large amounts of food in a short time (for example, within two hours), more than most people would eat in similar circumstances. The person feels a loss of control during these episodes, unable to stop eating or control how much they eat.

2. Recurrent Behaviors to Prevent Weight Gain, such as:

• Self-induced vomiting
• Overuse of laxatives or diuretics
• Fasting for long periods
• Excessive, compulsive exercise

3. Repetition of these Behaviors: Binge eating and compensatory behaviors happen at least once a week for three months in a row.
4. The impact of weight and body image on Self-Evaluation: The person places an unhealthy emphasis on their weight or appearance when judging their self-worth.

Note: Absence of Anorexia Nervosa Symptoms:

If these symptoms occur with an extremely low body weight, the condition is diagnosed as anorexia nervosa (type 2), which involves bingeing and compensatory behaviors, rather than bulimia.

Common Symptoms of Bulimia

• Frequent episodes of overeating, characterized by:
  1. Eating large amounts of food within a specific time frame (e.g., one or two hours), and more than most people would eat in similar circumstances.
  2. Inability to control eating during these episodes (feeling unable to stop eating or stop eating certain foods).
  3. Recurrent compensatory behaviors to prevent weight gain, such as self-induced vomiting, excessive use of laxatives, fasting, or overuse of diuretics.
  4. These episodes occur at least once a week.

• Self-esteem is heavily influenced by weight and body size
• Secretive eating and hiding food due to shame and embarrassment
• Digestive issues
• Fluctuations in weight
• Massive  fear of gaining weight
• Feelings of guilt and shame after binge episodes
• Persistent anxiety
• Difficulty concentrating
• Social isolation
• Obsession with diets, counting calories, macros, and grams

Physical Consequences/Symptoms of Bulimia:

1. Frequent sore throat (due to vomiting)
2. Esophageal problems
3. Bloating, abdominal pain, and chronic constipation (due to excessive use of laxatives)
4. Tooth decay and enamel erosion
5. Gum infections
6. Menstrual disturbances and sometimes amenorrhea (absence of menstruation)
7. Dehydration
8. Low levels of potassium, magnesium, and sodium, that may increase the risk of arrhythmias (irregular heartbeats)
9. Low blood pressure and weakened heart muscles

Studies show that individuals with bulimia suffer from anxiety and depression at significantly higher rates, with up to 60-70% of those with bulimia experiencing anxiety or depression.

“I always used to take a laxative after having a large meal that was more than my usual. It was very uncomfortable because it caused severe cramps, but I thought it was the right thing to do. Eventually, I developed lazy bowels, as my body got used to these pills.”

Leen, recovered client, 23yrs 

Causes

Bulimia can affect anyone, regardless of age (though it is more common among teenagers and women). However, there are psychological, social, and genetic factors that increase the risk of developing it.

Genetic Factors: There is a link between family history of eating disorders and mental health issues and the development of this disorder, suggesting that genetics play a role.

Psychological Factors: Anxiety disorders, depression, post-traumatic stress disorder (PTSD), low self-esteem, and exposure to trauma, especially during childhood, increase the risk.

Social Factors: These factors certainly play a significant role. In societies that encourage weight loss and idolize thinness, the number of people following diets has increased in the last century, which corresponds with the rise in eating disorders.

Treatment

The ideal treatment for bulimia requires a comprehensive approach that targets psychological, medical, and nutritional factors.

Steps in recovery include:

1. Psychotherapy

Psychological modalities that focus on behavioral therapy such as CBT help modify unhealthy thoughts and behaviors related to eating and body image. Some clients may benefit from coaching as it provides daily and meal support in addition to alleviating some of the burden placed on family members.  

2. Family Therapy

Especially important for adolescents, family therapy helps families support the individual in a healthy and effective way.

3. Medication

Antidepressant medications can help alleviate symptoms such as anxiety and depression and improve control over compulsive behaviors (prescribed by a doctor when necessary).

4. Nutritional Therapy

A balanced eating plan developed with a nutritionist and eating disorder specialist to rebuild healthy eating habits and promote a healthy relationship with food. 

5. Medical Care

Ongoing monitoring of health issues caused by the disorder, such as electrolyte imbalances, tooth damage, and effects on the heart and kidneys.

6. Social Support

Participating in support groups can help the patient share their experience and feel understood and accepted.

Treatment requires time and patience, with a strong commitment to the treatment plan and regular progress tracking with the specialized team to ensure full recovery and prevent relapse.

“Overcoming bulimia is like learning to breathe again—you stop suffocating under the weight of shame and control, and instead, you inhale freedom, exhale self-love, and reclaim the peace you thought was lost.”

Author Unknown 

Frequently Asked Questions

1. Is bulimia considered a psychological or behavioral disorder?

Bulimia is considered both a psychological and behavioral disorder. Although the behaviors associated with bulimia, such as binge eating and purging, may seem behavioral, psychological factors play a significant role in the development of the disorder. For instance, obsessive thoughts about food, body image distortion, and weight anxiety increase the likelihood of compulsive behaviors.

2. Does bulimia affect cognitive abilities in the long term?

Yes, it can. Repeated behaviors like vomiting or laxative use cause imbalances in electrolytes, which can affect cognitive functions such as memory and concentration. Additionally, mental health disorders like depression and anxiety can exacerbate these effects, contributing to decreased cognitive performance.

3. How does the support of family and friends contribute to recovery from bulimia and eating disorders in general?

Family and social support play a crucial role in the recovery process. Research shows that families providing an emotionally supportive and stable environment can significantly improve recovery outcomes, Family therapy can help individuals understand the impact of eating disorders on daily life and promote more effective communication and stronger personal relationships However, support must be balanced, as forced interventions may lead to resistance to treatment.

4. What is the relationship between bulimia and other chronic health problems?

Bulimia can increase the risk of chronic health issues such as heart disorders, bone density loss, liver and kidney problems, and gastrointestinal disorders. The physical health effects can sometimes be long-term, requiring continuous medical monitoring and comprehensive treatment to address the damage caused by behaviors associated with bulimia.

6. Can I have both anorexia and bulimia at the same time?

Yes, it is possible for a person to suffer from both anorexia nervosa (anorexia) and bulimia (bulimia nervosa) simultaneously. This is sometimes referred to as “mixed eating disorder” (Type 2 anorexia), where the individual exhibits a combination of behaviors associated with both disorders.

If you or a loved one are struggling with a disordered relationship with food, I can help you as a health coach certified in both Intuitive Eating and eating disorder recovery. Fill out this form and I will be in touch very soon with an honest answer of the best course of action for you. 

Resources:

BioMed Central 

National Eating Disorders Association (NEDA)

Mayo Clinic