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Insidious Bulimia Nervosa: Developments, Symptoms, and Referring for Help


Bulimia Nervosa (BN) is the second most common eating disorder (ED). It is a neuropsychological disorder that potentially can be life-threatening if not treated, which affects both genders. The prevalence of this eating disorder varies between 0.3% and 4.6% in females and from 0.1% to 1.3% in males. Interestingly, the prevalence rates vary drastically between Western and Eastern countries, with BN diagnosis being more than 7 times higher in Western when compared to Eastern cultures.

Diagnostics and symptoms

Noticing that someone is suffering from BN can sometimes be difficult as it can occur at a normal, slightly elevated, or highly elevated weight. According to the International Classification of Diseases (ICD-11), the symptomatology of BN includes, but is not limited to:

  • Frequent and recurrent episodes of binge eating (e.g., once a week or more over a period of at least one month)
  • Repeated inappropriate compensatory behaviors to prevent weight gain occurring after the episodes of binge eating (e.g., induced vomiting, misuse of laxatives, period fasting, extensive exercise, use of enemas)
  • Excessive preoccupation with weight and body shape
  • Marked distress about the pattern of binge eating and inappropriate compensatory behavior or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning

The symptoms of BN should not meet the definitional requirements for Anorexia Nervosa (AN), i.e., if the weight is estimated to be lower than the marked threshold (BMI <18.5) the diagnosis of Anorexia Nervosa is given with binge/purge subtype as a classifier.

The effects of BN

BN evokes severe effects on overall physical health and psychological well-being.

  • Brain: depression, fear of gaining weight, anxiety, dizziness, shame, and low self-esteem
  • Cheeks, mouth, throat, and esophagus: swelling and sores on inner cheeks, poor dental health due to enamel erosion, dental sensitivity to temperature, cavities, gum diseases
  • Blood, hormones, and body fluids: a coexisting diagnosis of anemia is common, low pulse and blood pressure, irregular or absent menstrual cycles, dehydration causing low levels of minerals such as potassium, magnesium, and sodium
  • Heart: arrhythmia, weakening of the heart muscles, heart failure in extreme cases
  • Skin: abrasion of knuckles caused by self-induced vomiting, as knuckles often are bruised by the front teeth trying to evoke pharyngeal reflex, overall dried-out skin
  • Stomach and Intestines: increased risk of ulcer and ruptures, constipation or diarrhea, irregular bowel movements, abdominal cramping, bloating
  • Muscles: fatigue

Development of ED

It is proposed that the most common EDs, including AN, BN, and Binge Eating Disorder (BED), take on a similar state like development:

Onset → Happy Starvation → Painful hunger → Desperation → Identifying with ED

The onset of the disorder is often associated with a negative life event, which results in loss of self-esteem or identity crisis. In order to cope or protest a particular negative experience, an individual seeks out control, affirmation, and relief. In the case of AN and BN, the focus point becomes food intake, count of calories, and overall change of previously established feeding behaviors.

During the stage of happy starvation, an individual observes rapid results, i.e., weight loss (physical), and a sense of control, which leads to euphoric-like emotions (psychological). Environmental reinforcements play a big role in sustaining the stage of happy starvation, which is usually accompanied by positive attention from peers, family, and compliments. The length of the happy starvation stage can vary drastically between individuals, from 2 weeks up to 6 months.

Given that the period of happy starvation puts immense stress on the body, the painful hunger stage involves the physiological consequences of restricted feeding behaviors. During this stage, a variety of negative physical and psychological factors play a role in either:

  1. Recovery from unhealthy feeding behavior - coming back to regular/normal emotional and physical functioning
  2. Development of AN by continued starvation
  3. BN consumption of food followed by compensatory behaviors
  4. Development of Binge Eating Disorder

During this time, peers, family, or friends might express concerns about the observed changes (rapid weight loss, irritability, mood swings, loss of menstrual cycles, etc.). This stage is accompanied by profound unhappiness (partly due to malnutrition,) and a sense of loss of control. The individual might exhibit social isolation in order to avoid discussing the ED with close others.

The stages of painful hunger and desperation are, at times, difficult to separate. The individual experiences intrusive thoughts regarding feeding behavior and commonly “the loss of control of the control.” Not being able to control feeding behaviors (proxy for sense of control), their own thoughts, or experiences of somatic symptoms, can lead to anxiety and isolation.

Finally, the individual starts to identify oneself with the ED, where it becomes hard to imagine life without an ED. This stage is also associated with strict refusal of treatment, even when life-threatening symptoms are present.

It is important to note that there is no certain length of the described stage-like development of ED. There is vast individual variability between patients in both the development and treatment of ED.

Referring to a clinician

As is the case with the majority of eating disorders, getting professional psychological help is often avoided. The first step of getting help is admitting that there is a problem. Many find it easier to first rely on a close relative for support before approaching the physician. The appointed physician is likely to notice or refer an individual for additional check-up based on the following symptoms:

  • An unusually low or high body weight for specific age
  • Rapid weight loss
  • Menstrual or other endocrine disturbance
  • Unexplained gastrointestinal symptoms
  • Physical signs of malnutrition, including poor blood circulation, weakening of heart muscles, dizziness, palpitations, fainting or pallor or/and unexplained electrolyte imbalance or hypoglycemia
  • Other mental health problems (e.g., obsessive-compulsive disorder, depression)
  • Problems managing a chronic illness that affects diet (e.g., diabetes or coeliac disease)
  • For children/adolescents: can have faltering growth (e.g., low weight or height for their age) and/or delayed puberty
  • Abdominal pain that is associated with vomiting or restrictions in diet that cannot be fully explained by a medical condition
  • Atypical dental wear (e.g., erosion)

References:

Galmiche, M., Déchelotte, P., Lambert, G. & Tavolacci, M. P. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am. J. Clin. Nutr. 109, 1402–1413 (2019).

Gibson, D., Workman, C. & Mehler, P. S. Medical Complications of Anorexia Nervosa and Bulimia Nervosa. Psychiatr. Clin. North Am. 42, 263–274 (2019).

Oldershaw, A., Startup, H. & Lavender, T. Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa. Frontiers in Psychology vol. 10 (2019).

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