Bulimia nervosa: Meaning, symptoms, Causes, Prevention, Treatment options, Ayurveda Understanding

Article by Dr Manasa S, B.A.M.S

Introduction to Bulimia Nervosa

Bulimia nervosa, often referred to simply as bulimia, is a serious and potentially life-threatening eating disorder. Individuals with bulimia experience episodes of binge eating, where they consume large amounts of food in a single sitting, often in secret. This loss of control is followed by feelings of guilt and shame, leading to purging behaviours such as vomiting or misusing laxatives to eliminate the consumed calories.

People with bulimia are typically preoccupied with their weight and body shape, often judging themselves harshly for perceived flaws. This disorder is not merely about food but is deeply connected to self-perception. While challenging to overcome, effective treatment can improve self-esteem, promote healthier eating habits, and mitigate severe complications.

Causes of Bulimia

Bulimia nervosa does not have a single known cause, but it is believed to result from a combination of various factors:

Genetic Factors: Genetic predisposition may play a significant role in the development of bulimia.

Family History: A family history of eating disorders can increase the likelihood of developing bulimia.

Past Traumatic Events: Experiencing trauma, such as abuse or significant life stressors, can contribute to the onset of bulimia.

Social and Cultural Influences: Societal and cultural pressures emphasizing thinness and appearance can influence bulimia’s development.

Serotonin Deficiencies: Research suggests that bulimia may be associated with deficiencies in serotonin, a neurotransmitter that regulates sleep, mood, and appetite.

Symptoms of Bulimia

Fear of Weight Gain: Persistent fear of gaining weight, leading to unhealthy weight loss methods.

Binge Eating: Repeated episodes of consuming unusually large quantities of food in one sitting.

Loss of Control: Feeling unable to stop eating or control food intake during binges.

Purging Behaviour: Inducing vomiting or engaging in extreme exercise to prevent weight gain after binge eating.

Misuse of Medications: Using diuretics, laxatives, or enemas unnecessarily to pass stool or lose weight.

Fasting and Food Restrictions: Alternating between binge eating and fasting, limiting calorie intake, or avoiding specific foods.

Dangerous Supplements: Using dietary supplements or herbal products for weight loss, which can be hazardous.

Body Dissatisfaction: Extreme dissatisfaction with body shape and weight.

Self-Worth Linked to Appearance: Basing self-esteem and self-worth on body shape and weight.

Mood Swings: Experiencing severe mood swings.

Risk Factors of Bulimia

Family History and Genetics: Having first-degree relatives (siblings, parents, or children) with eating disorders increases the risk, indicating a possible genetic link.

Mental Health Issues: Depression, anxiety, and substance misuse are closely associated with eating disorders. Bulimia is often linked to low self-esteem and emotional distress, sometimes stemming from bullying about weight or shape.

Emotional Distress: Distressing events, such as childhood mistreatment, can contribute to the development of bulimia.

Dieting: Strict calorie restriction between binge-eating episodes can lead to a cycle of binge eating and purging. Stress, intense emotions, negative body image, and boredom are also triggers for binge eating.

Complications of Bulimia Nervosa

Bulimia nervosa is a psychiatric disorder with severe medical complications that arise based on the frequency and methods of purging used by the patient.

Dental Complications:

–        Dental enamel erosion: Gastric acid from vomiting can erode tooth enamel, particularly on the occlusal surfaces, leading to increased dental decay and gingival recession.

Gastrointestinal Complications:

–        GERD (Gastroesophageal Reflux Disease): Frequent vomiting can lead to chronic acid reflux, increasing the risk of Barrett’s oesophagus, where abnormal mucosa replaces normal oesophageal tissue, potentially leading to cancer.
–        Mallory-Weiss syndrome: Forceful vomiting can cause tears in the oesophagus, which might progress to oesophageal rupture (Boerhaave’s syndrome).
–        Irritable Bowel Syndrome (IBS): A high prevalence of IBS is noted among bulimia patients.
–        Constipation: Chronic use of laxatives can lead to cathartic colon syndrome and severe constipation.
–        Rectal prolapse: This can occur due to constipation or the pressure from frequent vomiting.
–        Recurrent acute pancreatitis: Documented in several cases of bulimia nervosa.

Respiratory and Throat Complications:

–        Laryngopharyngeal reflux: Stomach contents can move back into the throat, causing coughing, hoarseness, sore throat, and swallowing difficulties.

Salivary Gland Issues:

–        Salivary gland hypertrophy: Frequent vomiting can cause swelling of the parotid and submandibular glands, leading to noticeable swollen cheeks.

Oesophageal Issues:

–        Achalasia: The inability of the lower oesophageal muscles to relax.
–        Oesophageal spasm: Irregular contractions of the oesophageal muscles.

Cardiac Issues:

–        Cardiac arrhythmia: Hypokalaemia from vomiting can lead to dangerous heart rhythms, including QTc prolongation. Abuse of ipecac can further cause heart complications, including congestive heart failure.

Metabolic and Systemic Issues:

–        Diabetes: Bulimia nervosa has been associated with an increased risk of type 2 diabetes.

Long-term Outlook:

–        Mortality: Bulimia nervosa is associated with increased all-cause mortality.

Some interesting facts about Bulimia nervosa

Bulimia nervosa is a complex eating disorder with various causes and effects. Here are 12 interesting facts that shed light on this condition:

1.Rooted in Compulsive Habits: People with bulimia often engage in compulsive behaviours related to food, such as binge eating and purging. This can involve forced vomiting, excessive use of laxatives, or extreme fasting.

2.Mental Disorder Classification: Bulimia is not only an eating disorder but also a mental health condition. It can lead to severe health issues and is associated with high rates of depression and suicide.

3.Societal Pressure Influence: The societal obsession with thinness is believed to contribute to the development of bulimia. The pressure to conform to beauty standards can push individuals towards unhealthy eating behaviours.

4.Genetic Factors: Bulimia can run in families, suggesting a genetic component. If a parent has an eating disorder, their children may be more likely to develop one, though environmental factors also play a role.

5.Affects Both Genders: While more common in women, bulimia also affects men. Approximately 15% of those treated for bulimia are male, though they might show fewer symptoms and be less likely to seek help.

6.Normal Body Weights: Unlike anorexia, people with bulimia often maintain a normal body weight, making the disorder less noticeable to others. This can lead to delayed diagnosis and treatment.

7.Serious Health Consequences: Bulimia can cause numerous health issues, including anaemia, low blood pressure, dry skin, ulcers, dehydration, and severe gastrointestinal problems.

8.Reproductive Health Risks: Women with bulimia may experience irregular menstrual cycles and have higher risks during pregnancy, including miscarriage, stillbirth, and birth defects.

9.Antidepressants for Treatment: Medications like Prozac (fluoxetine) are FDA-approved for treating bulimia, particularly for those who also suffer from depression. These can help reduce binge-purge cycles.

10.Lifelong Battle: Recovery from bulimia is possible but often involves a lifelong struggle. Relapses can occur, emphasizing the need for ongoing treatment and awareness of triggers.

11.Not Just About Food: Bulimia is more than an obsession with food; it’s often tied to deeper emotional issues, including anxiety, low self-esteem, and trauma. Addressing these underlying factors is crucial for recovery.

12.Role of Therapy: Various forms of therapy, including cognitive-behavioural therapy (CBT) and family therapy, are effective in treating bulimia. These therapies help individuals understand and change their unhealthy behaviours and thought patterns.

Understanding these facts can help dispel myths about bulimia and highlight the importance of comprehensive treatment for those affected by this serious disorder.

Diagnosis and Tests for Bulimia

Physical Examination: A thorough physical check-up by a doctor.

Blood and Urine Tests: Tests are ordered to assess overall health and detect any imbalances.

Psychological Evaluation: Performed to understand the individual’s relationship with food and body image.

DSM-5 Criteria:

–        Recurrent binge eating.
–        Regular purging through vomiting, excessive exercise, misuse of laxatives, or fasting.
–        Self-worth derived from weight and body shape.
–        Binge eating and purging occurring at least once a week for three months.
–        Absence of anorexia nervosa.

Severity Classification (DSM-5):

–        Mild: 1 to 3 episodes per week.
–        Moderate: 4 to 7 episodes per week.
–        Severe: 8 to 13 episodes per week.
–        Extreme: 14 or more episodes per week.

Evaluation of Bulimia Nervosa

Evaluating a patient with bulimia nervosa requires a comprehensive approach that includes various laboratory tests and assessments to understand the medical and physiological impacts of the disorder. Key components of the evaluation include:

Complete Blood Count and Comprehensive Metabolic Panel:

–        A complete blood count (CBC) with a differential should be performed to assess the overall health and detect potential complications such as anaemia or infection.
–        A comprehensive metabolic panel (CMP) is crucial to evaluate electrolytes, liver function tests, blood urea nitrogen (BUN), serum creatinine, and calcium levels.

Laboratory Abnormalities:

–        Patients with bulimia nervosa often exhibit laboratory abnormalities such as hypokalaemia (including hypokalaemic hypochloremic metabolic alkalosis), hyponatremia, and elevated liver enzymes (transaminitis).

Electrocardiogram and Serum Tests:

–        For severe cases, additional tests such as serum magnesium and phosphorus levels should be obtained.
–        An electrocardiogram (ECG) is essential to monitor for any cardiac abnormalities that might arise due to electrolyte imbalances.

Urinalysis:

–        A urinalysis helps in detecting any kidney-related issues and provides further insight into the patient’s hydration status and overall renal function.

Specialized Testing for Female Patients:

–        Female patients should undergo a pregnancy test to rule out pregnancy as a potential contributor to amenorrhea.
–        For those experiencing secondary amenorrhea, it is important to test for luteinizing hormone (LH), prolactin, beta-HCG, and follicle-stimulating hormone (FSH) levels to identify other possible causes of the amenorrhea.

Vitamin B12 and Laxative Use:

–        Consider obtaining a vitamin B12 level to check for deficiencies that could contribute to the patient’s symptoms.
–        Lab tests are available to detect stool or urine bisacodyl, emodin, aloe-emodin, and rhein. However, a positive test for a stool or urine laxative is not essential for diagnosing bulimia nervosa.

This comprehensive evaluation framework ensures that both the psychological and physiological aspects of bulimia nervosa are addressed, enabling appropriate treatment planning and management.

Preventive Measures for Bulimia

Promote a Healthy Body Image: Encourage confidence in various aspects of personality, not just appearance, regardless of size or shape.

Regular Family Meals: Have enjoyable and consistent family mealtimes to foster a positive relationship with food.

Avoid Discussing Weight: Refrain from talking about weight or body shape at home.

Discourage Unhealthy Dieting: Prevent unhealthy weight-control behaviours, such as fasting, labelling foods as good or bad, using supplements or laxatives, and vomiting.

Early Detection: Consult with a primary healthcare professional to identify early signs of eating problems.

Open Communication: If you observe potential food issues in a loved one, consider discussing your concerns with them and ask them how you can help them out and be supportive.

Treatment and Management

Primary Objective

– Cease binging and purging behaviour.

Medications

Selective Serotonin Reuptake Inhibitors (SSRIs):

–        Fluoxetine, citalopram, and sertraline reduce symptoms.
–        Fluoxetine is FDA-approved for bulimia nervosa.
–        Higher dose (60 mg) of fluoxetine is effective in decreasing binge and vomiting episodes.

Other Medications:

–        Trazodone reduces binge-eating episodes.
–        Monoamine oxidase inhibitors and tricyclic antidepressants for resistant cases due to lethality and side effects.
–        Avoid bupropion due to increased risk of epileptic episodes.
–        Topiramate reduces binge episodes but requires monitoring for weight loss and cognitive issues.

Psychotherapy

–        Cognitive-Behavioural Therapy (CBT): Effective in treating bulimia nervosa.
–        Interpersonal Psychotherapy (IPT): Also beneficial for patients.

Screening and Risk Management

–        Screen for suicidality and comorbid psychiatric illnesses.

–        Bulimia nervosa patients are at higher risk for other mental diseases.

Medical Complications and their treatments

Metabolic Alkalosis: – it is common due to fluid volume depletion. It should be treated with saline administration and cessation of purging. For inpatients, consider intravascular administration but monitor for volume overload.

Dehydration: Treated similarly on the lines of metabolic alkalosis. Intravenous saline not indicated for patients with normal / increased fluid volume and alkalemia.

Constipation: Adequate hydration, exercise, and dietary fibre. For the first line of management. If needed, use low doses of polyethylene glycol powder or lactulose.

Cardiac Complications: Cardiac complications are often due to electrolyte derangements. Severe or symptomatic cases may require a cardiology consultation.

Related studies and research

Study – A study ‘A controlled family study of anorexia nervosa and bulimia nervosa’ – states that there may be a common vulnerability for anorexia nervosa and bulimia nervosa.

Bulimia Nervosa: Ayurveda Understanding

There is no condition explained in Ayurveda which can be exactly correlated with Bulimia Nervosa. But this condition can be understood with the help of many related basics from Ayurveda scriptures. The understanding can be through inference and the assumptions are hypothetical, purely done to understand the given condition and not for exact correlation. This understanding will help in planning Ayurveda treatment protocols for Bulimia Nervosa.

Basically, Bulimia Nervosa is an eating disorder but is directly related to certain patterns happening in the mind of the person.

So, it should be understood on the lines of Manasika Roga – mental / psychological disorders and imbalances of the mind doshas. The functions and actions of mind as explained in Ayurveda treatises will throw more light in understanding this condition.

Since there is uncontrolled eating or binge eating in this disorder and the ultimate consequence is ati santarpana i.e. over-nutrition, the effect of Bulimia and the symptoms or complications which follow shall be considered from the viewpoint of ‘santarpana’ and ‘santarpanottha rogas’ – diseases caused by over-nutrition.

Bulimia Nervosa shall also be understood from the viewpoint of description laid in the context of diseases like medo roga, sthoulya, grahani, unmada – mainly bhutonmada, graha dosha, deviations or perversions of dhee, dhrti and smrti.

Treatment principles include avoiding the causative factors and Sattvavajaya Chikitsa – psychotherapy, balancing the dhi, dhrti and smrti components, implementation of skilful and logical methods of langhana and apatarpana, identifying the root diseases and addressing them and divine therapies and Panchakarma therapies as and when needed.

Related Reading – ‘Bulimia Nervosa – Ayurveda Understanding’