bulimia

Quick Overview

• Description: widespread eating disorder with change of strictly controlled eating habits and food cravings
• Main symptoms: “Gingerbread” with subsequent vomiting, excessive exercise, fasting
• Consequences: Malnutrition, tooth damage, gastritis, inflamed esophagus, cardiac arrhythmia, kidney damage, osteoporosis
• Causes: weak self-esteem, pursuit of recognition, adaptation to prevailing ideals of beauty, family influence on eating behavior and self-acceptance, genetic causes, biological triggers
• Diagnosis: standardized questionnaires and interviews on the symptoms and causes
• Therapy: cognitive behavioral therapy, re-learning healthy eating habits, individual and group therapy, antidepressants, mostly inpatient treatment

Bulimia: description

Bulimia (bulimia nervosa) is one of the eating disorders. Colloquially, we also referred to it as eating-crushing addiction. Typical bulimia symptoms are food cravings in which those affected devour uncontrollably large amounts of food. In order not to increase, they then take drastic countermeasures.

Psychic backgrounds

People with bulimia aspire to a figure that corresponds to the prevailing, overly slender ideal of beauty. By doing so, they hope for recognition and affection. It seems threatening to take them, because they are afraid of exclusion. Often a diet is the entry into the eating-crushing addiction.

Bulimia: symptoms

A bulimia is not as easy to see for outsiders as an anorexia. People who suffer from eating-crushing addiction are usually normal-or just slightly underweight. Some are even overweight. In addition, the seizure-seizures usually take place in secret, so that nobody notices something for a long time.

Most of the time, bulimics control their eating habits. They keep diet and let meals fail. But then they come over again cravings.

Repeated episodes of feeding attacks

During a ravenous attack, bulimia sufferers lose all control. They devour large quantities of very high-calorie foods in a short time. The loss of control can be so strong that they are initially unaware of their actions. In about one to two hours bulimics sometimes take up to 10,000 calories. That’s more than four times what a healthy person needs in a full day. Women have a need of about 1900 kilocalories per day.

The bingeing attacks are often triggered by stress and last so long until an unpleasant feeling of fullness arises. While they devour the food, some sufferers feel a brief relaxation. After the bingeing but they are usually ashamed of their behavior, disgusting or blame themselves.

Measures against weight gain

In order not to increase, people with bulimia try to get the food undigested again as possible from the body or otherwise counteract. There are two types of bulimics:

Countermeasure vomiting (purging type): About 70 to 90 percent of bulimics belong to the “purging type”. In most cases, they vomit the food immediately. For this they provoke nausea with the finger. Some patients also use aids, such as wooden spoons, with their stems stuck around their necks. Some try to keep their weight instead (or more) by fasting, laxative or extreme exercise.

To control whether they have vomited all of their food, many bulimia patients eat a colored food such as tomatoes at the start of binging.

Some purging-type bulimics also use laxatives or make enemas.

Countermeasure fasting and sport (non-purging type): Patients of the “non-purging type” do not reduce their weight by vomiting, but by severe fasting and excessive physical activity. This type, however, is less common than the purging type.

Pay attention to figure and weight

Like anorexics, people who suffer from bulimia pay a lot of attention to their weight and are very worried about it. The external appearance is crucial to their self-esteem. Only slim bodies are beautiful. The exaggerated fixation on figure and diet is often the symptom that attracts outsiders first.

Differences between bulimia and anorexia

Bulimia and anorexia (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. The psychological background of the diseases are fundamentally different.

bulimia	anorexia
The aim is a very slim figure (slight underweight)	A strong underweight is considered ideal, which others consider unhealthy and unattractive
Yearning for recognition and belonging	Pursuit of demarcation, self-control
Weight loss 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 loss of control and capture
Shame for the disease	Proud of the capacity for asceticism
Maintains sexual partnerships	Rarely sexual partnerships
Serious secondary diseases possible, fatal complications rare	High risk of fatal courses

Bulimia: Follow

A pronounced bulimia causes great damage in the body.

• Malnutrition: Repeated diets, constant vomiting, but also the use of laxatives can disturb the electrolyte balance and cause malnutrition.
• Heart failure: Too low a potassium concentration in the blood and cells can result in an irregular heartbeat and heart failure.
• Osteoporosis: Calcium deficiency makes the bones fragile.
• Kidney damage: The electrolyte deficiency can cause life-threatening kidney damage.
• Abdominal pain and stomach tear: Overeating inflates the stomach. This causes a lot of pain. In the worst case, a life-threatening tear in the stomach (stomach rupture) may arise.
• Constipation: Vomiting slows down the transport of food in the body. There are blockages.
• Tooth damage: The consequences of bulimia are often noticeable on the teeth. The stomach acid first destroys the enamel and then the dentin. As a result, the teeth may initially be sensitive to pain and temperature and then damaged.
• Oesophagitis: The ascending gastric acid causes mucosal inflammation of the esophagus (esophagitis). If gastric juice gets into the airways, there is an extreme risk of suffocation or pneumonia.
• Gastritis: In addition, when vomiting the stomach is irritated and can also inflame (gastritis). Constant vomiting then often leads to further injuries, including painful bleeding, scarring and organ perforations.
• Bauspeicheldrüsenentzündung: The binge attacks may develop a pancreatitis. She is noticeable by severe abdominal pain, fever and increased heart rate.
• Menstrual disorder and infertility: Frequently, in women with bulimia, menstruation becomes irregular or stays off. Fertility also decreases.
• Skin changes: In 10 to 30 percent of bulimia patients are also dry skin and brittle hair with hair loss consequences. Due to frequent vomiting, the salivary glands swell and the corners of the mouth become sore.
• Spiritual changes: Bulimia affects mood and concentration. Half of those affected also change the shape of the brain (pseudoatrophy). However, the causes and effects of this phenomenon are not clear.
• Risks in pregnancy: Due to malnutrition, unborn children of bulimic mothers often do not develop properly. The child may sustain permanent damage.

Bulimia: causes and risk factors

Why a person suffers from bulimia, is not yet clear. When the disease breaks out, several factors often come together. Risk factors include:

• genetic predisposition
• biological components
• lack of self-esteem
• problematic family influences
• high performance claim
• Western beauty ideal
• Negative self-image

People with bulimia often have a negative self-image. Between the claim “how I want to be” and the perception “as I really am” there is a deep gap. This is especially true for your own body. Self-esteem depends heavily on the character. Bulimic women usually strive for an extremely slim ideal, which they can only achieve by massive restriction when eating – or just by vomiting.

Extreme performance claim

The self-esteem of patients depends heavily on their success in achieving ambitious goals. At the same time they are extremely self-critical, which leads to constant dissatisfaction with their own achievements.

The conflict between exaggerated expectations of oneself and fears of failure and feelings generates strong states of tension. The seizures can mitigate this tension for a short time.

Problematic family behavior patterns

How food is treated within the family can contribute to eating disorders. In particular, it is critical if food is used to distract, reward or relax.

Negative influence seems to be restricted diet and dieting of the mothers, as well as a critical attitude to the own body within the family.

Often there are problems in dealing with each other family members. According to some experts, bulimics often come from families who are particularly ambitious and performance-oriented, or who impose their conflicts impulsively and violently.

Also, some experts describe a lack of warmth, attention and recognition in the family dealing with each other.

All this can but does not have to be the case. Whether such familial constellations actually contribute specifically to bulimia, or generally promote emotional lability, is also unclear.

Western beauty ideal

Bulimia is often favored by the desire to conform to the ideals of beauty in society. The current ideal is strongly towards underweight. It also motivates normal-weight people to make diets.

Often, patients with bulimia are slightly overweight before the onset of eating-crushing addiction. They then feel unattractive and find it difficult to accept their body. Through dieting, they try to come closer to the ideal of beauty. This is often the start of a bulimia.

Due to the constant starvation, the desire for food is strongly fueled. After all, they can no longer withstand the pressure and the vicious cycle of eating-crushing addiction begins. The momentum of bulimia can then be stopped only with professional help.

Biological factors

serotonin: This messenger substance creates feelings of happiness, but it also influences the feeling of satiety in the brain. It has been found that people with bulimia produce less serotonin.

Since the body needs carbohydrate-rich food for the formation of the messenger substance, this is a possible explanation for the seizures: About the massive intake of carbohydrates, people try to regulate negative feelings with bulimia. However, it is unclear whether the disorder in the messenger system is actually the cause of bulimia or rather occurs during bulimia and stabilizes it.

Body own opioids: Body opioids also seem to play a role in bulimia. These are substances that can reduce or suppress the sensation of pain and appetite.

It is believed that high levels of opioids during starvation facilitate fasting while elevating mood. Researchers have found very low levels of endogenous opioid bulimics. This triggers food cravings and thus also the bingeing. In this way, low levels of opioid might contribute to bulimia.

Genetic causes

There is also a hereditary predisposition to the eating disorder. This is indicated in particular by twin studies. If a twin suffers, the other has a much higher risk of developing identical bulimia in monozygotic pairs of twins than in dizygotic twins.

How big the influence of genes actually is, however, is not yet certain. Overall, he seems bulimia but not as large as anorexia (anorexia).

Bulimia: examinations and diagnosis

If there is a suspicion of bulimia, it makes sense to first visit the family doctor. He can refer you to specialized doctors and psychologists.

Whether a patient suffers from bulimia, the doctor can find out during an anamnesis interview. The doctor might ask the following questions to the patient if they suspect bulimia:

• Do you feel too fat?
• Are you satisfied with your body?
• Do you pay much attention to how much and what you eat?
• Do you have cravings where you can not stop eating?
• Does it happen that you vomit the ingested food again? How common is that?
• Do you have physical ailments such as muscle weakness, constipation, severe constipation?

Most sufferers hide their eating-breaking behavior. Many are not sure if this is even pathological. Others falsely believe that they can control the pathological behavior themselves. Equally, it is a great challenge for the patient and the doctor to build up such trust that the person concerned can open up to the doctor and help himself.

Psychological diagnostics

If the family doctor detects a bulimia, he will provide the affected person with psychotherapeutic help. Since bulimia has predominantly psychological causes, treatment of the physical complaints is not sufficient.

The psychotherapist can use a clinical interview to record specific mental health problems. He can also determine if the patient suffers from other disorders. People with bulimia often also suffer from depression, anxiety disorders or personality disorders.

Diagnostic criteria of bulimia

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the following characteristics are considered as bulimia signs.

• repeated episodes of feeding attacks
• repeated use of inappropriate weight-loss countermeasures
• The binge eating and the inappropriate compensatory behavior occur on average at least twice a week for at least three months.
• Figure and body weight have an excessive influence on the self-evaluation.
• The symptoms do not occur exclusively in connection with anorexia.

To record the diagnostic criteria, special questionnaires have been developed, which are supplemented by interviews. This includes the extensive Structured Clinical Interview for DSM-IV (SKIB interview). It includes not only the eating disorder but also other mental illnesses.

The Structured Interview for Anorexia and Bulimia (SIAB) consists of a questionnaire for self-assessment and an interview section with 87 questions that the doctor or psychologist goes through together with the patient.

Physical examination

In addition to the psychological diagnosis, a physical examination is necessary.

The doctor also examines the blood, which is often poor in vital salts due to vomiting. He also checks whether the stomach, esophagus and teeth are injured or attacked by gastric acid.

If the lack of salts already causes kidney damage or cardiac arrhythmia, the doctor tests the function of these organs via ECG, cardiac echo and an ultrasound of the kidneys.

Bulimia Test

On the Internet, there are a number of online offers for the bulimia test. Such tests are based on the questions that a doctor would ask, for example

• about eating habits and diets
• to attitude to your own body
• to self-esteem
• especially to the eating attacks themselves
• self-induced vomiting, laxative consumption and sports excesses

A safe diagnosis for bulimia can only be an expert, but the online tests provide guidance. Thus, a bulimia test on the Internet can encourage the person concerned to think about his eating habits and to seek help if necessary.

Bulimia: treatment

Bulimia is a serious mental disorder. People with bulimia, however, find it difficult to realistically assess their eating habits, or they do not want to believe that it is disturbed. Therefore, professional help with bulimia is indispensable. The main goals in the treatment of bulimia are

• to quickly achieve a rapid change in eating habits in order to restore or maintain physical health.
• To help those affected in the long term to recognize the causes of disturbed eating behavior and to eliminate it or to find other ways to deal with it.

Normalization of eating behavior

In mild cases, bulimia can also be treated on an outpatient basis. In severe cases, however, the diet must be controlled so that patients can find their way back to healthy eating habits. This is usually possible only in a stationary frame.

Not too much and without vomiting

At the beginning of the treatment, a balanced meal plan is created together with the patient, which he then has to comply with. This includes having regular meals – at least three a day. It’s about eating without falling into a binge or vomiting the food.

To be afraid of calories

Patients learn to eat even higher-calorie foods that they avoid outside the eating-crushing attacks without fear. They are also involved in the preparation of the meal. The handling of food should become a positive, relaxed experience for her.

Normalized eating urge

Due to the regular and varied diet of the physical deficiency is terminated. As the patient no longer goes through periods of hunger, the urge to incorporate large amounts of food becomes less.

psychotherapy

Cognitive-behavioral therapy is often used to treat bulimia.

Realistic body image: Patients should develop a more realistic attitude to their body and their weight. It is also about questioning the social ideals of beauty and slimming.

Find trigger: In collaboration with the therapist, bulimia patients explore which situations induce a gastric seizure. A food diary can help. The therapist then tries to find alternative ways and behaviors with the patient to deal with stressful situations.

Exposure therapy: Bulimia therapy often works with so-called confrontations, which serve to reduce anxiety. The therapist encourages patients to face situations or to consume foods that cause them anxiety and that otherwise trigger a seizure. The therapeutically accompanied argument leads to a constant reduction of the fears and increases the self-esteem and the self-esteem of the bulimics.

Wide range of therapies

An inpatient stay typically uses a wide range of holistic treatment therapies. This includes:

• individual therapy
• group therapy
• gestalt therapy
• Art therapy
• movement therapy
• music therapy
• relaxation courses
• nutrition counseling

Medication

At the beginning of bulimic therapy and in crisis, some patients temporarily receive antidepressant substances. Above all, the drug fluoxetine is used for this purpose. Not only does it have an antidepressant effect, it also reduces the eating-vomiting attacks. As a sole treatment for bulimia drugs are not suitable.

Bulimia: disease course and prognosis

Bulimia usually begins in adolescence or early adulthood. Especially women between the ages of 18 and 30 fall ill, but increasingly also young men. Bulimia can be preceded by a period of heavy weight loss, which then turns into eating-and-vomiting attacks. Often diets are the entry into the eating-crushing addiction.

In the course of the disease there are always times when bulimia sufferers eat normally. The number of Ess-Brech seizures varies individually. In stressful periods, when patients are particularly stressed, eating-break-off attacks occur frequently.

Bulimia is often treated only in the third decade of life of the patient, ie after a long period of illness. After all, about half of the patients who suffered from bulimia, healthy, but usually only after several years of disease.

Additional information

Books:

• Back to life: Bulimia in 12 steps (Nina Wolf, Tectum Wissenschaftsverlag, 2018)
• The Woman Who Eat in the Moonlight: Overcoming Eating Disorders Through the Wisdom of Ancient Tales and Myths (Anita Johnston, Knaur MensSana TB, 2007)

guidelines:

S3 Guideline “Eating Disorders, Diagnosis and Therapy” of the German Society for Psychosomatic Medicine and Psychotherapy (DGPM)

Support Groups:

Cinderella – Advice Center for Eating Disorders of the Action Group for Eating and Anorexia e.V.

https://www.cinderella-beratung.de/