Although the literal meaning of bulimia is “hunger like an ox,” bulimia nervosa (usually referred to simply as bulimia) is a condition characterized by recurrent episodes of binge eating that may have little or nothing to do with actual physiological hunger. These episodes of bingeing are then followed by recurrent compensatory behaviors intended to prevent weight gain.
A formal diagnosis of bulimia is made when someone:
- Engages in repeated episodes of binge eating, characterized by
- Eating in a discrete amount of time (e.g within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
- A sense of lack of control; that the person cannot stop eating or control what or how much they are eating
- Engages repeatedly in inappropriate compensatory behavior designed to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting, or excessive exercise
- Engages in the binge eating and inappropriate compensatory behaviors on average, at least twice a week for three months
- Experiences that self-evaluation is unduly influenced by body shape or weight
- Does not experience these disturbances exclusively during episodes of anorexia nervosa
Bulimia can also present as two different sub-types. Many people with bulimia tend towards the purging type, where they regularly engage in self-induced vomiting, or the misuse of laxatives, diuretics, or enemas. Others may use inappropriate compensatory behaviors such as fasting or excessive exercise, but will not regularly engage in vomiting, laxatives, diuretics, or enemas.
Someone might meet all of the diagnostic criteria for bulimia, or he or she might meet just a few. What’s most important is getting expert help as soon as possible in order to prevent health risks and allow them to feel better. According to the Mayo Clinic, bulimia may cause a host of serious and even life-threatening complications. The specific complications someone experiences may be related to his or her choice of purging method, such as overexercise or laxative abuse, and how severe their condition is.
- Heart problems, such as abnormal heart rhythms and heart failure
- Tooth decay
- Amenorrhea (In females): As the body registers too great a caloric deficit, estrogen levels drop and menstruation ceases, increasing the risk for erosion of bone density (osteopenia, osteoporosis) and infertility
- For males, undernutrition and weight loss can lead to changes in testosterone levels, also resulting in weaker bones and increased risk for fractures.
- Gastrointestinal problems, such as constipation, bloating or nausea. May also include pre-cancerous changes to the esophagus (Barrett’s Esophagus), as well as irritation of the stomach, salivary glands, and throat from persistant vomiting
- Electrolyte abnormalities, such as low blood potassium, sodium and chloride, as well as dehydration from repeated vomiting.
- Increased susceptibility to depression and anxiety, as well as an increased risk of suicidality
It can be difficult to understand why anyone would repeatedly engage in a behavior that is ultimately harmful, but it’s important to remember that eating and exercise disorders are, first and foremost, an attempt at a solution.
Eating disorders often begin with a sense of dissatisfaction that is perceived to be about the body. People start to diet or exercise, never intending or anticipating that they will develop a serious problem. As they engage in the dieting and exercise behaviors, however, and particularly if their efforts are praised or reinforced by other people, the changes in behavior and changes in body size and shape can begin to take on powerful psychological functions. People may find that the disorder provides them with a sense of control, self-esteem, identity, power or safety that felt lacking for them previously. Suddenly, they find that the choice of what to have for breakfast, or whether or not to exercise, is emotionally “loaded” out of all proportion to rationality, and because of that, it becomes enormously difficult to challenge the disordered behaviors, even if they know the consequences are negative.
For people dealing with bulimia, the experience is further complicated by the fact that they alternate between restrictive eating (which may feel good emotionally, but which becomes impossible to tolerate physically), and bingeing (which is emotionally distressing, but physiologically and psychologically driven). Purging, also, can gain a lot of psychological momentum as a perceived means to control size and shape, and as a behavior that can manage emotions. And unfortunately, the more that someone purges or restricts their eating, the more likely it becomes that they will eventually binge. If they respond with more restriction or purging, the cycle starts all over again. Choices about eating, exercise, or purging that once felt voluntary quickly become obligatory. That eating disorders take on a life of their own psychologically, is strongly reinforced by genetic susceptibilities that can heighten an individual’s response in terms of brain chemistry, metabolism, and other important physiological processes.
In a culture that glorifies body types radically at odds with physiological health, and that normalizes extremes of behavior with dieting and exercise, it can be difficult for someone with an eating disorder to believe that they have a problem with food, exercise, or weight. Even if he or she is able to acknowledge some concern, the fear of losing what might feel like their primary source of safety or self-esteem is often powerful enough to make them want to defend or preserve this way of coping.
Dan Reiff, MPH RD, and co-author of Eating Disorders: Nutrition Therapy in the Recovery Process, uses an analogy he calls “The Helicopter Story.” In it, he likens the ambivalence of someone considering eating disorder recovery to a person, unable to swim, who has been stranded in the middle of the ocean with only a life-jacket to keep them afloat. Rescue by helicopter will prevent them from ultimately drowning or dying of hypothermia, but the helicopter team tells the swimmer that he or she will need to give up their life-jacket in order to be pulled on board. It’s a daunting prospect, and it’s also the reason why people with eating disorders need time and lots of expert support in order to give up their behaviors and recover completely.
It is now becoming clear that genetics and biological predisposition play a critical, though not exclusive role in the development of an eating disorder. Studies of people with anorexia and bulimia have found links to specific chromosomes, and a 2006 study led by the University of North Carolina, Chapel Hill, estimated that 56% of the responsibility for developing anorexia nervosa is determined genetically. Other studies have examined variations in serotonin and dopamine receptors in patients with anorexia and bulimia which could serve to reinforce eating disorder symptoms like food restriction.
Firstly, it can lessen some of the shame and blaming that goes on when someone develops an eating disorder. Too often, people with eating disorders blame themselves for becoming preoccupied with food and their bodies, not realizing the extent to which these obsessions can be driven by biological susceptibilities. People can be much more compassionate with themselves when they understand that—even though there may have been times when they’ve consciously chosen to use a disordered behavior in order to cope—they didn’t choose the disorder itself. Understanding the biological contribution may also allow some people to feel less shame about utilizing psychiatric medications like antidepressants or anti-anxiety drugs as part of their recovery.
Does this mean that socio-cultural factors aren’t important in the development of an eating disorder?
Not at all. Plenty of people have variable neurotransmitter levels and do not struggle with eating or body image, and many other people with eating disorders have no corresponding predisposition. Even for people with a predisposition, it is the environment in which they live that can mitigate or promote the expression of their genetic tendencies. This is one of the reasons that it remains critical to address the “thinness culture.” Another is that dieting—with its potential for malnourishment and disruption of brain chemistry—can contribute to an existing problem in susceptible individuals, or create a completely new one to deal with. In fact, dieting has been called “ a necessary, but not sufficient condition for the development of an eating disorder.” When it comes to understanding and treating eating disorders, it’s important to think in terms of both nature AND nurture.
If you are worried that a friend has bulimia, click here for information and resources.
When medical support, nutrition work and psychotherapy are utilized, recovery is completely possible for individuals with bulimia. Chances for complete recovery are highest when people receive early, specialized treatment at the right level of intensity.
To get the support that you need at Brown University, follow the links below.
BWell Health Promotion 401.863-2794
Located on the third floor of Health Services.
Confidential information or care is available through individual appointments or phone consultation with a Nutritionist. Students can discuss personal eating concerns, as well as any concerns they may have regarding a friend, a roommate, or a teammate. Health Promotion also offers workshops, pamphlets, and reading materials covering these and related issues. There are no fees for Health Promotion services.
University Health Services 401.863-3953
Located at the corner of Brown and Charlesfield streets.
Confidential information and care is available on a walk-in, or by scheduled appointment basis. Care is available for initial, current or past disordered eating patients. There are no fees for medical care at Health Services. However, there may be fees incurred if laboratory tests, medications, specialist or emergency hospital care is needed.
Counseling and Psychological Services 401.863-3476
Located on the fifth floor of J. Walter Wilson.
Confidential appointments are available at Counseling and Psychological Services for students concerned about their eating issues. Guidance is also available for those who are concerned about a friend, roommate, or teammates' eating. Services include crisis intervention, short-term psychotherapy and referrals. There are no fees for appointments at Psychological Services.
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This site looks at ways we can feel good in the bodies we have. One of their slogans: "Remember, your body hears everything you think." Other topics on the web site: Size Acceptance; What do you say when everyone around you is dieting? 200 Ways to Love the Body You Have; Dieting Detox; Evaluating Weight Loss Programs: What are the Red Flags? Free subscription to email newsletter "Body Positive Pages."
This site provides signs of eating disorders, motivational support talks, information on cultural issues and how to help loved ones.
National Eating Disorders Association
This site provides general information about eating disorders and body image concerns, tips for helping a friend and referral sources.
Eating Disorders Referral and Information Center
Provides information and treatment resources for all forms of eating disorders.
The American Dietetic Association
Articles from the ADA on eating disorders, including The Female Athlete, Compulsive Eating and Anorexia.
Adapted from the Boston College Eating Awareness Team
Disclaimer: BWell Health Promotion is part of Health Services at Brown University. Health Promotion maintains this site as a resource for Brown students. This site is not intended to replace consultation with your medical providers. No site can replace real conversation. Health Promotion offers no endorsement of and assumes no liability for the currency, accuracy, or availability of the information on the sites we link to or the care provided by the resources listed. Health Services staff are available to treat and give medical advice to Brown University students only. If you are not a Brown student, but are in need of medical assistance please call your own health care provider or in case of an emergency, dial 911. Please contact us if you have comments, questions or suggestions.