Bulimia Nervosa

What Causes Bulimia Nervosa?

Scientists continue to explore the behavioral, psychological, and social aspects of eating disorders. While the exact causes of binge eating and bulimia remain unknown, researchers suspect that genetics often plays a role.

To avoid gaining weight after overeating, people:

• Force themselves to vomit.
• Exercise too much.
• Use over-the-counter medications to make themselves vomit, urinate, or have bowel movements.
• Focus their attention on weight and food.

People with binge eating disorder and bulimia often deny that they have a problem. They try to hide their eating disorders from family, friends, and doctors.

Is Bulimia Nervosa Hereditary?

A new understanding of the role of genetics in eating disorders is bringing insights into how heredity influences people with bulimia. Many genes contribute to the development of an eating disorder. Research suggests that an individual’s vulnerability to the condition results from a complex interplay of environment and genetics.

Certain personality traits are seen in bulimia — perfectionism, anxiety, and obsessive tendencies — may be influenced by genetics. Studies have pinpointed particular genetic variants on several chromosomes that may add up to a greater risk for binge eating and vomiting. Family history suggests that inherited traits may influence the likelihood of using self-induced vomiting as a coping mechanism.

Although eating disorders have long been considered primarily sociocultural, scientists think that people with bulimia are likely to come from families where the condition is common. Research shows that self-induced vomiting tends to run in families.

Scientists suspect that abnormal levels of a critical neurotransmitter, serotonin, increase susceptibility to bulimia. Researchers at the University of California San Diego Eating Disorder Center have linked bulimia to reduced serotonin levels. Even after recovery from bulimia, low serotonin levels persist. Bingeing on high-carbohydrate foods can raise serotonin levels in the brain and stimulate feelings of pleasure. Scientists think that bulimia probably results from a genetic predisposition triggered by life events and the family environment.

How Is Bulimia Nervosa Detected?

Bulimia nervosa usually appears in adolescence or the early adult years. Peer pressure, identity issues, and family stresses often seem overwhelming as teens move from childhood into adolescence. Cultural stereotypes about beauty and body shape influence young people in not-so-subtle ways.

The most common signs of bulimia include overeating, excessive exercise, preoccupation with body weight, and the irrational fear of becoming fat.

Common warning signs of bulimia include:

• Rapid heartbeat
• Low blood pressure
• Blood-tinged vomit
• Dry skin
• Swelling of the salivary glands in front of both ears
• Irregular or missed menstrual periods
• Acid reflux disease (GERD)
• Erosion of dental enamel

How Is Bulimia Nervosa Diagnosed?

Although overeating and inactivity can account for weight gain, a substantial group of obese people also suffers from binge eating. During binges, people overeat and feel guilty, ashamed, and out of control.

Bulimia nervosa is diagnosed when unhealthy purging behaviors and excessive exercise accompany binge eating. People with bulimia follow binge eating episodes with laxatives, diuretics, self-induced vomiting, fasting, diet pills, and excessive exercise to prevent weight gain.

Severely bulimic patients may need tests to check their levels of essential electrolytes like calcium, magnesium, and phosphorus. Electrolyte imbalances commonly result from frequent purging.

The following tests are used to diagnose bulimia:

• Blood and urine tests can show abnormal nutrient levels and dehydration (a severe drop in water levels in the body).
• Liver function and kidney tests reveal potential damage to organ systems.
• An electrocardiogram (EKG) records the electrical activity in the heart and measures heart rate and rhythm.
• A psychiatric exam focuses on the individual’s attitude about body weight and shape, self-esteem, and mental health disorders that could affect treatment.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Bulimia Nervosa Treated?

Because of the secrecy and shame around eating disorders, only about one in 10 people with bulimia nervosa receive treatment. Even with treatment, relapse is common. Although males account for only about 10-15% of people with bulimia, eating disorders among male athletes are rising, especially in sports where weight is restricted.

Since many people with bulimia struggle with obsessive thoughts, therapy is vital to recovery from eating disorders. Treatment for bulimia focuses on understanding the behavioral, psychological, cultural, and treatment needs of individual binge eaters and bulimics. Obese or overweight people often benefit from a medically supervised behavioral weight-loss program. Those with a substance abuse disorder may need counseling, medications, and self-help support groups.

Many people with bulimia work with an eating disorders team that includes a mental health clinician, nutritionist, and medical support. Antidepressants have been shown to improve symptoms of bulimia, especially in people who also suffer from depression.

A mental health clinician may coordinate care in an outpatient setting or an eating disorder treatment center. Since people with bulimia often struggle with perfectionism and low self-esteem, long-term therapy leads to better outcomes. Psychological treatment to tackle flawed thinking and poor self-image often integrates several different therapies:

• Acceptance and Commitment Therapy (ACT) is a type of psychotherapy that helps people accept things mainly out of their control. ACT helps individuals give up harmful or self-destructive bulimic behaviors by encouraging flexibility and new ways of thinking.
• Individual, group, and family psychotherapy. The multifaceted approach focuses on thinking and behaviors. A psychotherapist works one-on-one to support the individual. Family therapy helps parents and adolescents work through relationship problems or interpersonal issues related to bulimia. Some therapists use additional treatment modalities for children or those with a history of trauma.
• Cognitive-behavioral therapy (CBT) is the leading evidence-based treatment for adults with eating disorders. CBT is considered the “gold standard” treatment for bulimia. The therapy addresses cognitive factors like negative body image, core beliefs about self-worth, and perfectionism. CBT also helps people with binge eating disorders. Mindfulness-Based Cognitive Behavior Therapy integrates concepts of mindfulness into the treatment approach.
• Dialectical behavioral therapy (DBT) combines mindfulness with techniques for healthy emotional regulation. The focus is on acceptance (rather than change) and learning to cope with difficult emotions.
• Pharmacotherapy. Antidepressant medication is prescribed for bulimia. Prozac® (fluoxetine) is the only medication approved by the Food and Drug Administration (FDA) to treat bulimia. The usual dose is 60 mg of Prozac to help control symptoms. Additional medications may be prescribed for concurring mental health problems, such as bipolar disorder or obsessive-compulsive disorder.

How Does Bulimia Nervosa Progress?

While symptoms vary widely, people with bulimia nervosa are at risk for medical complications. Shortness of breath, chest pain, joint pain, gastrointestinal problems, menstrual problems, and headaches occur more often in individuals with either bulimia nervosa or binge eating disorder than those without a psychiatric disorder.

People with bulimia often suffer from other  mental health disorders:

• Depression. Some depressed people try to make themselves feel better by binge eating and purging. Depression causes disruptions in sleep, appetite, energy levels, and memory. Treatment is urgently needed if someone with bulimia and depression becomes suicidal.
• Anxiety disorders. People try to handle worry or obsessive thoughts by binge eating and/or purging. Mood disorders are common in people with bulimia.
• Alcohol or drug abuse. Many research studies have linked substance abuse and other addictive behaviors with eating disorders. Nearly one in 10 people with bulimia also have a substance abuse disorder, usually alcohol use.

Over time, bulimia causes a range of worsening medical problems:

• Fatigue and tiredness
• Irregular menstrual cycles and missed periods
• Belly pain, bloating, and constipation
• Damage to the esophagus (the tube that runs from the throat to the stomach)
• Severe tooth decay and gum disease

Bulimia often has lasting effects on reproductive health. The danger is most significant when women get pregnant during episodes of active bulimia. Pregnant women are at greater risk for miscarriage, stillbirth, diabetes, and high blood pressure, as well as birth complications and/or defects.

As the disorder progresses, bulimia can cause various medical issues, ranging from irregular heartbeat to high blood pressure, severe headaches, and seizures. Heart failure is among the leading fatal effects of bulimia. In very severe cases, dehydration can lead to kidney failure.

How Is Bulimia Nervosa Prevented?

While it’s difficult to prevent bulimia nervosa, professional treatment can make all the difference before the situation worsens. Early intervention can teach people better ways to cope with their feelings. Studies show that professional help — and even self-help cognitive behavioral therapy techniques — help individuals who are motivated to stop bingeing and purging. Unresolved personal trauma can contribute to binge eating and bulimia.

Examples of common “triggers” for binge eating include:

• Grief. The loss of an important person.
• Interpersonal role disputes. Conflicts with a spouse, parent, or coworker.
• Role transition. A significant change in someone’s life circumstances or relationships.
• Interpersonal problems. Social isolation or difficulty maintaining relationships.

Bulimia Nervosa Caregiver Tips

The most important thing you can do for a loved one with bulimia nervosa is to be supportive. Try these helpful strategies:

• Get an accurate diagnosis.
• Look into a treatment center that specializes in eating disorders.
• Watch for missing food, such as bags of chips, cartons of ice cream, or other signs of binge eating.
• Set a good example by not overeating or dieting. Keep only healthy food in the house.
• Be alert to signs of purging, such as vomit-stained towels.
• Find therapists who can understand bulimia and can help individuals learn new coping skills.
• Create a robust support system. The free recovery group Overeaters Anonymous welcomes people with bulimia as well as other eating disorders. Find a local group.
• Connect with others for support. Support groups can help people who are struggling to help someone recover from binge eating or bulimia.

Many people with bulimia also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with bulimia:

• About half of people with bulimia also suffer from depression.
• Two-thirds of people with bulimia have an anxiety disorder such as social anxiety disorder, phobias, or obsessive-compulsive disorder (OCD) at some point in their lives.
• Nearly half of people with bulimia also experience post-traumatic stress disorder (PTSD).
• ADHD affects about one out of every three people with bulimia.
• About a third of people with bulimia struggle with alcoholism.

Bulimia Nervosa Brain Science

Scientists continue to investigate the neurobiology of binge eating and bulimia nervosa. Neurotransmitters that carry signals from the brain to the rest of the body play an important role in regulating mood and appetite. Researchers suspect that eating disorders may be caused by an imbalance in levels of the neurotransmitter serotonin.

Serotonin is a factor in other brain disorders, including anxiety and depression. Serotonin changes how efficiently neurons communicate with each other.  Brain scans show disruptions in cellular signaling in people with bulimia. As a result of the depletion of serotonin, people get too little of this vital neurotransmitter.

The antidepressant Prozac® (fluoxetine) is an SSRI (selective serotonin reuptake inhibitor) that blocks the chemical’s reabsorption to keep high serotonin levels. Serotonin receptors are not just found in the brain but throughout the body. About 80-90% of the human body’s total serotonin is contained in specialized cells in the gut, not in the brain. Bulimia damages the nerves that tell the brain that the stomach is full.

Although the neurotransmitter’s exact mechanism is not entirely understood, serotonin is known to help regulate mood, social behavior, appetite, digestion, memory, and more. Although research is more limited, researchers believe that people with binge eating disorder also have chronically low serotonin levels.

Research shows that bulimia is associated with lower levels of another key neurotransmitter, dopamine. Often thought of as the “pleasure” chemical, dopamine has been linked with the brain’s reward system. Alcoholism and other addictions — known to be related to dopamine levels — are prevalent in people with bulimia.  People with bulimia also often have difficulty with impulse control.

Eating is more rewarding and pleasurable for people with binge eating disorder than for healthy people. People with binge eating disorder use food as a reward to compensate for negative emotional states. Brain reward mechanisms drive people to consume large amounts of food during episodes of bingeing.

Binge eating is associated with the release of dopamine in some areas of the brain. Eating is more rewarding and pleasurable for people with binge eating disorder than for healthy people.

Bulimia Nervosa Research

Title: Neurobiology of Bulimia Nervosa

Stage: Recruiting

Principal investigator: Jessica Baker, PhD 

University of North Carolina

Chapel Hill, NC

This pilot study experimentally manipulates ovarian hormones to examine the direct impact of estrogen (E2) and progesterone (P4) on binge eating symptom burden and the behavioral reward response in women with bulimia nervosa (n=15). This is completed by taking medications that change ovarian hormone levels. This line of research could lead to the development of pharmacological interventions developed to target specific areas of the brain, brain receptors, or pathways identified to be involved in the mechanism underlying ovarian hormone change and binge eating. 

Title: A path to defining excellence in intensive treatment for eating disorders

Stage: Completed

Authors: Angela S. Guarda, MD;  Stephen A. Wonderlich, PhD; Walter H Kaye, MD

Johns Hopkins University

Baltimore, MD

In the United States, the past decade has seen rapid growth in treatment centers providing specialty care to patients with eating disorders. Much of this growth has been in higher levels of care, including hospital‐based and residential treatment. Despite this expansion, there remains a lack of agreement regarding the most important components of care, such as staff training or specifics of treatment delivery. Additionally, there is no consensus on how best to assess outcomes and compare performance across programs. This leaves patients, families, public and private insurance programs, and policymakers with limited information to help facilitate treatment decisions. The present paper considers the implications of these changes in the eating disorder treatment landscape and examines two ideas that, if implemented, may enhance the quality of eating disorder care. First, we explore the proposal to develop a network of centers of excellence in eating disorder treatment and the value this may have for improving overall treatment quality. This idea was discussed at an expert meeting held at SAMSHA in 2017 regarding issues important to the field following passage of the 21st Century Cures Act. Second, we consider the potential utility of a study using the Delphi method to promote expert consensus regarding clinical outcome assessments.