Bulimia is treatable, with full recovery possible. Those of us with an eating disorder will focus obsessively on our weight and be affected by the way we think we look versus the way we think we should look, which hugely affects our well-being.
Bulimia can be defined as recurring incidents of binge eating with attempts to get rid of calories and obstruct weight gain. Symptoms include self-induced vomiting, taking laxatives or diuretics and may include intensely exercising, and people of any weight can have bulimic symptoms. Some of those of us suffering from bulimia may have previously been diagnosed with anorexia nervosa, then regained weight and started patterns of binge eating and vomiting.
There are various emotional and behavioural symptoms of bulimia, including feeling out of control with food; feeling addicted to food; being scared of gaining weight; feeling bad about the body; acting confidently but having low self-esteem; feeling guilt and shame; feeling low and depressed; having mood swings, and feeling increasingly desperate and purging to control weight but still gaining weight. Purging often provides relief for difficult emotions and can help us feel instantly thin.
Eating disorders tend to surface after restrictive eating or dieting behaviour, often caused by pressures from society and the media to be thin. Too much restriction triggers the body into starvation mode where the body battles to maintain its weight by lowering its metabolism, increasing hunger hormones and decreasing satiation signals, which in turn directly affects subsequent weight gain and can lead to reactive binge eating.
Research has shown that too much restriction has long-term side effects such as cravings, depression and poor body image, which continue well after we have stopped restricting food. Behaviour becomes reinforced as weight gain and symptoms worsen, and binge eating and purging have an effect on our reward pathways in the brain. So dieting can trigger a bulimic pathway.
Bulimia Nervosa
This is repeated cycles of binge eating and self-induced vomiting, and possibly taking laxatives or diuretics. For those of us with bulimia, the rate of binge eating incidents per week varies from 1 to 46. For a diagnosis, this will have been happening for at least 3 months. Food that is binged on will normally be considered forbidden and fattening, and will be eaten until the urge to eat has disappeared, sometimes to the point of physical damage.
Atypical Bulimia
This is bulimia where the overeating is not extreme, or the purging behaviour doesn’t happen so frequently. Purging disorder is when we purge without having eaten excessively, in order to prevent weight gain. It’s categorized as an ‘Other Specified Feeding or Eating Disorder’ (OSFED).
Exercise Bulimia
This is exercising excessively and compulsively to compensate for overeating and may or may not occur alongside vomiting or taking laxatives.
Diabulimia
This dangerous and potentially fatal condition is where type 1 diabetics withhold injecting their insulin so they lose weight. Other medications can also be abused to control weight.
There are multiple physiological effects of purging. Metabolic changes affect every system in the body. There are changes in the heart, liver, kidneys, brain, endocrine system, gut bacteria, and gastrointestinal system. Purging can produce marks on the hand and swelling under the tongue. Taking laxatives and vomiting causes a loss of electrolytes from our cells, like potassium, and can cause kidney damage and heart problems. Cells lacking in potassium cannot burn energy efficiently, which causes easy weight gain. Laxatives also affect liver function and damage the gut wall. Dietary chaos also reduces serotonin levels, a hormone that stabilises our mood, and feelings of well-being and happiness. Binge eating leads to high blood glucose status, which results in a huge spike in insulin. This sucks too much sugar from the blood, leading to low blood glucose levels and strong cravings again, and the cycle continues. When average daily blood glucose levels and hence daily insulin levels are increased, this can lead to weight gain, further keeping the eating disorder cycle going.
We can often feel a lot better once we correct the physical imbalances that result in metabolic disruptions, abnormal cravings and low mood. Nutritional considerations are important in psychological treatment for bulimia. If we take laxatives, we may need medical support and are encouraged to slowly cut down on the number we take to reduce rebound water retention.
Certain ‘feel-good’ neurotransmitters, such as endorphins, serotonin and dopamine would have served us well in the hunter-gatherer environment that our bodies are still primed for, but in our current environment, they are often not so helpful. In a diet where excess sugar or highly refined flour foods are regularly consumed, this triggers frequent surges of serotonin which can result in a down-regulation of serotonin receptors and drive us to consume more of these ‘fast’ carbohydrates and sugars to achieve the same effect. It’s also now thought that in the case of vomiting, purging actually results in an increase in our dopamine and endorphins levels, in turn helping us to feel we can get on with our day. When this is happening regularly, these raised levels of dopamine can mean we become more immune to its rewarding properties, which can drive us to purge more to achieve the same effect. So in this way, purging can become an addictive process in itself. Purging is always addressed and managed as the first priority during treatment.
It is common for those of us suffering from bulimia to put on weight since we are likely to ingest and absorb thousands of calories, despite purging. We believe that purging prevents weight gain, which is a myth, as the average number of calories actually absorbed during a binge is 1200. Most calories are absorbed before laxatives can take effect too. As well as this, vomiting and laxative or diuretic abuse all trigger a loss of potassium which directly impacts our cells’ ability to burn energy efficiently, which results in easy weight gain.
There is often an illusion of weight loss after vomiting or taking laxatives, which could be due to a loss of water, as well as emotional relief.
Then if we restrict our food intake too much, certain physiological changes ensue and we get locked into a struggle with our body as it fights to resist the starvation process. When we restrict too much, we ignore our automatic appetite regulators and attempt to teach our body to stop responding to hunger and satiation cues. However, the hypothalamus in our brain acts to increase our appetite and decrease our metabolism, which results in ravenous hunger and reactive binge eating. This keeps the cycle going and has an impact on our weight.
The goal of bulimia treatment is to help you to eat a wide variety of foods without being worried about putting on weight or losing control, to see no food as forbidden, and to lose your cravings. Weight loss is not the goal of bulimia treatment, as weight change is only possible once your relationship with food has changed. The aim is for you to feel in control from within. Although antidepressants can be prescribed for bulimia, it’s important to know that people can and do recover without them.
You’ll need to complete a detailed questionnaire before starting our first session, which helps to inform the support that’s right for you. We will focus on: discovering what preceded the original development; managing the unhelpful thoughts which maintain it; correcting misunderstandings about food and what happens in our body; managing compulsive eating without purging (stopping purging is not correlated with weight gain); identifying and exploring coping mechanisms; exploring and managing emotions; adopting dense nutrition; increasing the domains of self-worth, and preventing relapses.