Julia Dobmeier is currently completing her master’s degree in clinical psychology. Since the beginning of her studies, she has been particularly interested in the treatment and research of mental illnesses. They are motivated in particular by the idea of providing those affected with a higher quality of life through easy-to-understand knowledge transfer.
Christiane Fux studied journalism and psychology in Hamburg. Since 2001, the experienced medical editor has been writing magazine articles, news and non-fiction on every conceivable health topic. In addition to her work for NetDoktor, Christiane Fux’s prose writing. Her first mystery novel was published in 2012, and she also writes, designs and publishes her own mystery novels.
Bulimia is a mental illness that belongs to the eating disorders. The persons concerned have recurring ravenous appetite attacks, in which they eat uncontrollably. After such "binge you are very afraid of gaining weight. Therefore, they vomit, take laxatives or exercise excessively. Read here what bulimia is, how to recognize it and how to treat it.
- Description: Widespread eating disorder with alternation of strictly controlled eating behavior and ravenous hunger attacks
- Main symptoms: "binge eating" with subsequent vomiting, excessive exercise, fasting
- Possible consequences:Malnutrition, dental damage, gastritis, inflamed esophagus, cardiac arrhythmia, kidney damage, osteoporosis
- Causes: Weak self-esteem, striving for recognition, conformity to prevailing beauty ideal, family influence on eating behavior and self-acceptance, genetic causes, biological triggers
- Diagnostics: Standardized questionnaires and interviews about the symptoms and causes
- Therapy: cognitive behavioral therapy, relearning healthy eating behavior, individual and group therapy, antidepressants, usually inpatient treatment
Bulimia (bulimia nervosa) is one of the eating disorders. Colloquially it is also called binge eating addiction. Typical bulimia symptoms are ravenous hunger attacks in which the affected person uncontrollably devours large amounts of food. In order not to gain weight, they take drastic countermeasures afterwards.
Eating disorders – and now?
Christiane Fux studied journalism and psychology in Hamburg. Since 2001, the experienced medical editor has been writing magazine articles, news and non-fiction texts on all conceivable health topics. In addition to her work for NetDoktor, Christiane Fux is also a prose writer. In 2012, her first crime novel was published; she also writes, designs and publishes her own crime novels.
The right way to deal with it
The secret illness
Worry about loved ones
Simply eat again?
Do not talk about eating
Time out from the disease
Relatives also suffer
Only the person affected can become active
Getting healthy takes patience
People with bulimia strive for a figure that corresponds to the prevailing, overly slim ideal of beauty. Thereby they hope for recognition and affection. Gaining weight seems threatening to them because they fear exclusion. Often a diet is the entry into the binge eating addiction.
Bulimia is not as easy for outsiders to recognize as anorexia, for example. People suffering from binge eating addiction are usually normal or only slightly underweight. Some are even overweight. Moreover, the binge-breaking fits usually take place in secret, so that no one notices anything for a long time.
Most of the time, bulimics strongly control their eating behavior. They are on a diet and skip meals. But then they are overcome again and again by ravenous appetite attacks.
Bulimia: "Offer to help."
Three questions to
Who is particularly affected by eating disorders?
Women in particular suffer significantly more often from eating disorders. Low self-esteem, excessive demands for performance and problematic family behavior patterns also contribute to the development of these problems. However, this is rarely triggered by a single factor, but rather by a combination of different factors, often accompanied by a one-time triggering event, such as a diet.
What’s the best way to address a bulimia suspect?
Best directly. Say you are concerned. Avoid criticism of eating behavior and reproaches. Speak in the first person and don’t press the issue. Instead, signal that the person means a lot to you and that you want to help. Asking for help is not a sign of weakness, but the first important step towards change.
Can bulimia patients get completely well again?
Relapses can occur especially at the beginning and in the first year after the end of treatment, the probability is approx. 30 percent. It is helpful to develop an understanding of risk situations. And come up with concrete, well-functioning coping strategies. Also, don’t judge a relapse as a complete failure, but as an incident from which you can learn something for the future.
Dr. med. Robert Doerr is head physician at the Schon Klinik Berchtesgadener Land in the field of psychosomatic medicine.
Repeated episodes of feeding frenzies
During a craving attack, bulimia sufferers lose all control. They devour large quantities of very high-calorie food in a short period of time. The loss of control can be so severe that they are initially unaware of their actions. In about one to two hours bulimics sometimes eat up to 10000 calories. This is more than four times what a healthy person needs in an entire day. Women have a need for about 1900 kilocalories per day.
The bingeing is often triggered by stress and lasts until an uncomfortable feeling of fullness develops. While devouring the food, some sufferers feel a momentary relaxation. After binge eating, however, they usually feel ashamed of their behavior, disgusted, or blame themselves.
Measures against weight gain
To avoid gaining weight, people with bulimia try to get the food out of the body undigested if possible or to counteract it in other ways. A distinction is made between two types of bulimics:
Countermeasure vomiting (purging type): About 70 to 90 percent of bulimics belong to the "purging type" to. In most cases, they immediately vomit up what they have eaten. To this end, they provoke emesis with their finger. Some patients also use aids, such as wooden spoons whose handle they stick down their throat. Some try to maintain their weight instead (or in addition) also by fasting, laxatives or extreme sports activities.
To check whether they have vomited all the food, many bulimia patients consume a colorful food such as tomatoes at the beginning of binge eating episodes.
Some purging-type bulimics also use laxatives or give themselves enemas.
Countermeasure fasting and exercise (non-purging type): Patients of the "non-purging type reduce their weight not by vomiting, but by strict fasting and excessive exercise. However, this type is rarer than the purging type.
Watching figure and weight
Similar to anorexics, people suffering from bulimia also pay close attention to their weight and are very afraid of gaining weight. The external appearance is crucial for their self-esteem. Only slim bodies they find beautiful. Excessive fixation on figure and diet is often the symptom first noticed by outsiders.
Differences between bulimia and anorexia
Bulimia and anorexia nervosa are not always easy to distinguish. In fact, bulimia often begins with a period of severe weight loss before binge eating and vomiting begin. However, the psychological backgrounds of the disorders are fundamentally different.
The aim is to achieve a very slim figure (slightly underweight)
Severe underweight is perceived as ideal, and is viewed by others as unhealthy and unattractive.
Longing for recognition and belonging
Striving for detachment, self-control
Weight loss in order to fulfill the prevailing ideal of beauty
Weight loss and refusal to eat as an expression of self-control, asceticism
Fear of abandonment, exclusion
Fear of losing control and being taken over
Shame for the disease
Pride in the ability to asceticism
Maintains sexual partnerships
Only rarely sexual partnerships
Serious secondary diseases possible, fatal complications rare
High risk of fatal outcome
A pronounced bulimia causes great damage to the body.
Due to constant vomiting, various deficiency symptoms and disturbances in the electrolyte balance occur. In addition, there is the chemical effect of gastric acid in the esophagus and mouth.
- Malnutrition: The repeated diets, constant vomiting, and also the use of laxatives can disturb the electrolyte balance and cause malnutrition.
- Cardiac insufficiency: Too low a concentration of potassium in the blood and cells can result in an irregular heartbeat and heart muscle weakness.
- Osteoporosis: Calcium deficiency makes bones brittle.
- Kidney damage: The electrolyte deficiency can cause life-threatening kidney damage.
- Abdominal pain and stomach rupture: Overeating causes the stomach to bloat. This causes severe pain. In the worst case, a life-threatening tear in the stomach (gastric rupture) can occur.
- Constipation: Vomiting slows down the transport of food in the body. Constipation occurs.
- Dental damage: The consequences of bulimia are often noticeable in the teeth. Stomach acid first destroys tooth enamel and then the dentin. As a result, the teeth can first become sensitive to pain and temperature and then become damaged.
- Esophagitis: Rising stomach acid causes mucosal inflammation of the esophagus (esophagitis). If gastric juices get into the airways, there is a risk of suffocation or pneumonia in extreme cases.
- Gastritis: In addition, vomiting irritates the stomach, which can also become inflamed (gastritis). Constant vomiting then often leads to further injury, up to and including painful bleeding, scarring and organ rupture.
- Salivary gland inflammation: Building salivary gland inflammation can develop as a result of the feeding episodes. It is noticeable through severe abdominal pain, fever and increased heartbeat.
- Menstrual disorders and infertility: Often in women with bulimia, menstruation becomes irregular or fails to occur. Fertility also decreases.
- Skin changes: In 10 to 30 percent of bulimia patients, dry skin and brittle hair with hair loss are further consequences. Frequent vomiting causes the salivary glands to swell and the corners of the mouth to become sore.
- Mental changes: Bulimia affects mood and concentration. In half of those affected, the shape of the brain also changes (pseudoatrophy). However, the causes and effects of this phenomenon are not clear.
- Risks in pregnancy: Due to malnutrition, unborn children of a bulimic mother often do not develop properly. The child may suffer permanent damage.
Bulimia: Causes and risk factors
Why a person becomes ill with bulimia has not yet been definitively clarified. When the disease breaks out, several factors often come together. Risk factors include:
- Genetic predisposition
- Organic components
- lack of self-esteem
- Problematic family influences
- high demand for performance
- Western ideal of beauty
- negative self-image
People with bulimia often have a negative self-image. Between the claim "how I want to be" and the perception and the perception of "how I really am there is a deep gap. This is especially true for your own body. Self-esteem is strongly dependent on the figure. Bulimics usually strive for an extremely slim ideal, which they can only achieve through massive restriction in eating – or, precisely, through vomiting.
Extreme benefit claim
The patient’s self-esteem is highly dependent on success in achieving ambitious goals. At the same time, they are extremely self-critical, which leads to constant dissatisfaction with their own performance.
The conflict between excessive expectations of oneself and fears and feelings of failure creates strong states of tension. binge eating can relieve this tension for a short time.
Problematic family behavior patterns
How food is handled within the family can contribute to eating disorders. It is especially critical when food is used as a distraction, reward or relaxation.
Restrained eating behavior and frequent dieting by mothers also seem to have a negative influence, as does a critical attitude toward one’s own body within the family.
Problems are often found in the way family members interact with each other. According to some experts, bulimics are more likely to come from families that are particularly ambitious and performance-oriented, or that deal with their conflicts impulsively and violently.
Also, some experts describe a lack of warmth, affection and recognition in family interactions.
All this can, but does not have to be the case. It is also unclear whether such family constellations actually contribute specifically to bulimia nervosa or promote mental instability in general.
Western beauty ideal
Bulimia is often promoted by the desire to conform to society’s ideals of beauty. The current ideal is going strongly in the direction of underweight. It motivates even normal-weight people to go on diets.
Often patients with bulimia are slightly overweight before the onset of binge eating disorder. They then feel unattractive and it is difficult for them to accept their body. Through diets they try to get closer to the ideal of beauty. This is often the first step toward bulimia nervosa.
Constant starvation strongly fuels food cravings. Eventually, they can no longer withstand the pressure and the vicious cycle of binge eating begins. The momentum of bulimia can then only be stopped with professional help.
Serotonin: This neurotransmitter produces feelings of happiness, but it also influences the feeling of satiety in the brain. People with bulimia have been found to produce less serotonin.
Since the body needs carbohydrate-rich food for the formation of the neurotransmitter, this is a possible explanation for the binge eating: Via the massive intake of carbohydrates, people with bulimia try to regulate negative feelings. However, it is unclear whether the disturbance in the neurotransmitter system is actually the cause of bulimia or whether it occurs during the course of bulimia and stabilizes it.
Endogenous opioids: Endogenous opioids seem to play a role in bulimia as well. Substances that can reduce the sensation of pain and appetite, or suppress them, respectively.
It is assumed that high opioid levels in hunger phases facilitate fasting and at the same time lift the mood. Researchers have found very low levels of endogenous opioids in bulimics. This triggers ravenous appetite and thus also the gluttonous attacks. In this way, low opioid levels could be contributing to bulimia nervosa.
There is also a hereditary predisposition to the eating disorder. This is indicated in particular by twin studies. If one twin falls ill, the other has a much higher risk of also developing bulimia in identical twins than in fraternal twins.
However, it is not yet certain how great the influence of the genes actually is. Overall, however, it does not seem as great in bulimia as in anorexia (anorexia nervosa).
Bulimia: examinations and diagnosis
If bulimia is suspected, it is advisable to first consult the family doctor. It can refer you to specialized doctors and psychologists.
The doctor can find out whether a patient suffers from bulimia during an anamnesis interview. The following questions could be asked by the doctor to the patient if bulimia is suspected:
- Feel too fat?
- Are you satisfied with your body?
- Pay close attention to how much and what you eat?
- Do you have food cravings where you can’t stop eating at all?
- Does it happen that you vomit up the ingested food again? How often is the?
- Do you have any physical complaints, such as muscle weakness, constipation, severe abdominal pain?
Most sufferers hide their binge eating behavior. Many are not sure if this is even pathological. Others mistakenly believe that they can control the pathological behavior themselves. It is a great challenge for the patient and the doctor alike to build up such a high level of trust that the person affected can open up to the doctor and allow themselves to be helped.
If the general practitioner diagnoses bulimia, he will refer the person to psychotherapeutic help. Since bulimia has predominantly psychological causes, treatment of the physical complaints is not sufficient.
The psychotherapist can use a clinical interview to assess specific psychological complaints. He can also determine if the patient suffers from other disorders. People with bulimia often also suffer from depression, anxiety disorders or personality disorders.
Bulimia diagnostic criteria
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the following are considered signs of bulimia nervosa.
- repeated episodes of binge eating
- Repeated use of inappropriate measures to counteract weight gain
- The binge eating and inappropriate compensatory behaviors occur on average at least twice a week for at least three months.
- Figure and body weight have an excessive influence on self-esteem.
- Symptoms are not exclusively associated with anorexia nervosa.
Special questionnaires, supplemented by interviews, have been developed to assess diagnostic criteria. This includes the comprehensive Structured Clinical Interview for DSM-IV (SKIB interview). It includes other mental illnesses besides eating disorder.
The Structured Interview for Anorexia and Bulimia (SIAB) consists of a self-assessment questionnaire and an interview section with 87 questions that the doctor or psychologist goes through with the patient.
In addition to psychological diagnosis, a physical examination is also necessary.
The doctor also examines the blood, which is often low in essential salts due to vomiting. Further check whether the stomach, esophagus and teeth are injured or affected by stomach acid.
If the lack of salts already shows kidney damage or cardiac arrhythmia, the doctor tests the function of these organs via ECG, cardiac echo and an ultrasound of the kidneys.
On the Internet, there is a whole range of online offers for the bulimia test. Such tests are based on the questions that a doctor would also ask, for example
- About eating behavior and dieting
- on the attitude to one’s own body
- about self-esteem
- especially about the binge eating itself
- to self-induced vomiting, laxative consumption and sports excesses
Only an expert can make a definite diagnosis of bulimia, but the online tests offer guidance. Thus, a bulimia test on the Internet can encourage the sufferer to think about his eating behavior and seek help if necessary.
Read more about the examinations
Find out here which examinations may be useful for this condition:
Bulimia is a serious psychological disorder. However, people with bulimia usually find it difficult to assess their eating behavior realistically, or they do not want to admit that it is disturbed. This is why professional help for bulimia is essential. The main goals in the treatment of bulimia are to,
- To achieve a rapid change in eating behavior in the short term in order to restore or maintain physical health.
- In the long term, help sufferers identify the causes of disordered eating behaviors and eliminate them or find other ways to deal with them.
Normalization of eating behavior
In milder cases, bulimia can also be treated on an outpatient basis. In severe cases, however, the diet must be controlled so that patients can return to healthy eating behaviors. This is usually only possible in a stationary setting.
Not too much and without vomiting
At the beginning of treatment, a balanced meal plan is drawn up together with the patient, who must then adhere to it. This includes eating regular meals – at least three a day. It is a matter of eating without going into an eating attack or vomiting the food.
Taking away the fear of calories
Patients learn to eat even higher-calorie foods that they have avoided outside of binge eating attacks without fear. They are also involved in the preparation of the meal. Handling food should become a positive, relaxed experience for them.
Normalized urge to eat
Regular and varied diet will end the physical deficiency state. Since the patient now no longer goes through hunger phases, the urge to eat large amounts of food is also reduced.
Cognitive behavioral therapy is often used to treat bulimia nervosa.
Realistic body image: Patients should develop a more realistic attitude about their body and weight. It’s also about questioning society’s ideal notions of beauty and thinness.
Looking for triggers: In cooperation with the therapist, bulimia patients find out which situations cause binge eating episodes. A food diary can help. The therapist then works with the patient to find alternative ways and behaviors to deal with stressful situations.
Confrontation therapy: In bulimia therapy, so-called confrontations are often used to reduce anxiety. Therapist encourages patients to expose themselves to situations or eat foods that cause them anxiety and that have otherwise triggered a binge eating episode. The therapeutically accompanied confrontation leads to a steady reduction of fears and increases the self-confidence and self-esteem of bulimics.
Wide range of therapies
During an inpatient stay, a wide range of therapies is usually used for holistic treatment. These include:
- Individual therapy
- Group therapy
- Gestalt therapy
- Art therapy
- Exercise therapy
- Music therapy
- Relaxation courses
- Nutritional advice
At the beginning of bulimia therapy and in crises, some patients receive temporary antidepressant substances. The drug fluoxetine is used for this purpose in particular. It not only has an antidepressant effect, but also reduces binge eating episodes. Medications are not suitable as sole therapy for bulimia nervosa.