In our high-pressure, image-focused society, some people turn to drastic, unhealthy measures to try to change their bodies. No one wants to develop an eating disorder, but what may start out as experimentation with a disordered eating behavior can escalate into a habit, and then a consuming lifestyle. In this blog, we will investigate bulimia — its causes, signs, risks and what you can do to help.
Bulimia Nervosa, as defined in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is an eating disorder in which a person must display the following:
1) Recurrent episodes of binge eating, which is characterized by:
a. eating an amount of food that is normally larger than most people would eat during a similar period of time and under similar circumstances in a discrete period of time (e.g. within 2 hours)
b. a sense of lack of control over eating during the episode (i.e. compulsive)
2) Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, diet pills, or other medications, fasting, or excessive exercise.
3) The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
4) Self-evaluation is unduly influenced by body shape and weight.
5) The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
People struggling with bulimia can be underweight or overweight, but quite often fall within a normal weight range. For this reason, unlike the more severe signs of weight loss in anorexia, many people with bulimia can go unrecognized as having it. Yet they still suffer with the intense fear of gaining weight, shame for not being able to stop eating, and a constant feeling of chaos akin to what substance abusers describe.
In addition, there is often an emotional parallel to the behaviors of bulimia. People who binge and purge often take on too much complexity, and then feel overwhelmed and want to shut down. This may happen in dating life, school or work obligations, and family dynamics.
There’s often a ritual to binging. People don’t usually binge on lean meats or vegetables alone, although they can. But more commonly, people binge on sugars, saturated fats, and starchy carbohydrates. Dietitians call these “highly palatable foods,” because they taste strong and go straight to the bloodstream. People who binge are often afraid to keep binge foods in the house. They may go through periods of trying to avoid binging by trying to be “good” and only eating foods they deem acceptable until they can no longer take it. When they feel compelled to binge, they’ll go to their rotation of grocery stores, convenience marts, or fast food restaurants so that people don’t notice the large quantities of foods they are getting. They may eat in their cars or at home in isolation due to shame around the inability to stop.
There is a significantly higher rate of depression in people with bulimia than the average population. Some have posited that one reason people crave a binge is because their bodies are searching to increase serotonin levels through carbohydrate intake. There may be a feeling of pleasure as the eating begins, but as people feel unable to stop, they start to feel more and more ashamed, as well as physically uncomfortable. There may be a feeling of powerlessness in thinking that they have “failed” their unrealistic expectations to eat a very strict diet. The urge to consume mass quantities is now replaced by overwhelming feelings of guilt and shame, and a panic to repent or compensate for the binge. This panic often gets relieved temporarily by purging, and thus, a cycle ensues.
The Compensatory Behaviors
All compensatory behaviors are specifically to make up for the episode of binging. For many people, the purging becomes a way to prevent weight gain and hide the consequences of binge eating from family members or loved ones. People struggling with bulimia may go out to eat with friends, but seem distracted and checked out while eating. Inside they’re conflicted with guilt and shame about what they’re eating. They’re trying to be social, but they’re consumed with panic. They can suddenly head to the bathroom after a meal to vomit.
Our bodies are designed to protect themselves from poisons by eliminating toxins through vomiting while retaining resources. When we vomit, our bodies release a natural tranquilizer called vasopressin, which retains water in the body, constricts blood vessels, and makes us feel better. Vasopressin lasts about 16-24 minutes in our brains and blood. However, it’s not meant to happen in our bodies with frequency. Used with frequency as a compensatory behavior, vasopressin is not very different neurologically than taking an opiate drug. People can become addicted to the numbing quality of relief and need greater amounts to achieve the same effect.
There are other ways to compensate for a binge besides vomiting. Some people use laxatives. People who use laxatives tend to have very little tolerance for the feeling of fullness in their bodies, especially in the lower half. This can often be accompanied on an emotional level by a sexual trauma history, a feeling of shame around a secret, sensory integration issues, or extreme rigidity. People who abuse laxatives often don’t want to go anywhere where they can’t be near a bathroom because of the unpredictability of having to use it. Their tummies can often growl audibly as fluids shift. Some people prefer to use diuretics to remove water retention in the body, in addition to or instead of laxatives.
Some people, in order to compensate for binging, will go through a cycle of restriction. What makes it disordered is that it’s not simply listening to a lack of hunger cues; it’s deciding not to eat to make up for eating too much. People may also try to burn calories through excessive exercise. The exercise is not regularly scheduled or out of joy; it is specifically to compensate for the episode of overeating. People with diabetes may try to manipulate their insulin to compensate for binging. This is called diabulimia. And lastly, people may take diet pills to try to speed their metabolism, in order to make allowances for the excess food.
The Risks and Complications
Although compensatory behaviors can provide very temporary relief of anxiety and depression, this relief comes at a high cost. Compensatory behaviors are shown to be ineffective at weight management, will often lead to water retention, and can cause dramatic shifts in weight and mood. In addition, there are many risks and complications.
When people stop purging after purging regularly, the parotid glands in the cheeks swell and it’s quite painful. This is because when people purge regularly, the body tries to dilute the extra acid in the mouth by producing extra salivary amylase. Some ice packs are helpful during this time. Eyes can become blood shot from straining. In addition, regular vomiting destroys tooth enamel and leads to tooth decay. Often, dentists are the first people to diagnose people for bulimia.
Regular vomiting and laxative abuse can cause all sorts of digestive problems, such as gastroparesis, a condition in which the bowels slow significantly or paralyze and have difficulty digesting fibers. Over time, it can impact bowels and lead to kidney failure. Excessive exercise can lead to all sorts of physical injuries.
Vomiting regularly can tear and destroy the esophagus with acid reflux. The stomach sphincter can loosen, allowing stomach acids to seep out and diminish digestive function. Regular purging of any kind (vomiting, laxatives, excessive exercise, diuretics, diet pills) can cause abnormal labs. Of significance are electrolyte imbalances, mainly of sodium and potassium, which can cause arrhythmias, tachycardia and even cardiac arrest and death! It’s not something to mess around with.
Now that you know the signs and symptoms of bulimia, you may wonder if you or someone you know may be struggling with this illness. The best time to get help is now. Don’t wait to feel “sick enough,” or for something catastrophic to happen. The sooner you get help, the better the outcome. Although eating disorders can be fatal, they are very treatable. Once the behaviors are contained for a few solid weeks, people can work out the underlying emotional issues and begin to lead happy, healthy lives.
The Institute for the Psychology of Eating
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