Bulimia

What is bulimia?
Bulimia is characterised by the following features:

  1. Recurrent episodes of binge eating. An episode of 'binge eating' includes:
    1. eating, in a discrete period 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 in similar circumstances.
    2. a sense of lack of control over eating during the episode, a feeling that one cannot stop eating or control what or how much one is eating.
  2. Recurrent, inappropriate compensatory behaviour in order to prevent weight gain, such as: self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise.
  3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for at least 3 months.
  4. Self-evaluation is unduly influenced by body shape and weight.

People with bulimia are very preoccupied with their weight or appearance. They tend to equate their sense of self esteem with how much they weigh, or what they perceive they look like. Bulimia is a highly self destructive condition in which people repeatedly swing between episodes of bingeing and episodes of compensatory 'deprivation', either through excessive dieting, purging (vomiting, laxatives, diuretics), or obsessive levels of exercise. The problem with this cycle is that it is self maintaining - the periods of deprivation actually set people up to 'bust' with a binge. The act of bingeing triggers 'all or nothing' thinking (e.g., "I've blown it! I have to do something to get rid of it!"), which then leads people to deprive themselves again. It's a vicious circle that maintains the problematic binge eating.

The 'vicious cycle' of bingeing and purging

How Common is Bulimia?

Eating disorders affect 2-3% of people, and most of these (around 90%) are women. Effective treatments for bulimia are available, and a good outcome can be achieved.

What Causes and Maintains Bulimia?

Many factors contribute to the development and maintenance of bulimia. The patterns differ from one person to another, and there is a highly complex relationship between the elements that combine to produce bulimia.

1. Physiological Factors
A number of studies have found that eating disorders run in families. A large scale twin study in 1991 (Kendler et al), found that if one identical twin had bulimia, the other twin was much more likely to also have bulimia than if the two twins were non-identical. This provides strong evidence for a genetic link for bulimia. However, exactly what features of bulimia are inherited is not yet known. It is likely that there is a very complex set of interactions between gene vulnerability, experience, and the environment. Just because someone in your family has an eating disorder does not sentence you to developing the same disorder. The picture is much more complex than that, and one that is not yet fully understood.

2. Social Factors
Bulimia as a recognisable disorder began to emerge in the 1970's and 1980's in those parts of the world which were developed and in which anorexia was already encountered: North America, Northern Europe, Australia, and New Zealand. Before this time, society encouraged all people, and especially women, to be rounder and more curvaceous. More recently, however, the cultural ideal is extreme slimness, and, according to advertisements and fashion magazines, even mature women should look like adolescent boys. Media influences everyone, and the clear message being sent to people today, particularly young women, is that to be very thin is desirable.

3. Psychological Features
There are a range of experiences and psychological and emotional features which have been linked to the development and maintenance of bulimia. Some of these include:

Trauma During Childhood - Traumatic childhood events including death, separation, parental discord, physical illness, teasing and bullying, and sexual abuse are often reported in bulimics.

Family Environment and Learning - It is not uncommon for adult bulimics to recall a family environment in which food, eating, or physical appearance was highly valued. One study examined the relationship between mothers and daughters with disturbed eating patterns (Pike & Rodin, 1991). The mothers of eating disturbed daughters differed from mothers of non-disturbed daughters in the following ways: they had more eating disturbance themselves, they thought their daughters should lose weight, and they were more critical of their daughter's appearance.

The messages that we get from our early environment are critical in how we form our self-identity. If the messages are unduly focussed upon appearance, weight, or food, it is possible that we will internalise belief systems which may increase vulnerability to developing an eating disorder.

Thinking Patterns - People with bulimia often display perfectionistic thinking patterns that tolerate no flaw in physical appearance, school work, athletic performance, professional achievement, or relationships. Perfectionism is damaging, as it is unrealistic as a personal standard. We can never `be perfect' in everything, all of the time.

Bulimics also tend to be 'all or nothing' thinkers. All or nothing is when things are viewed in black-and-white categories, with no shades of grey in between. For example, "I haven't reached my goal weight (thin), so I must be fat". "No-one will respect me unless I'm thin". "If I don't stick to every rule in the diet, it's a total failure". Or, "Vegetables are good. Chocolate is bad". All-or-nothing thinking is thinking in extremes.

4. Dieting
Dieting plays a role in initiating and maintaining bulimia. Dieting often begins before binge eating starts, but it also becomes a response to bingeing.
Fairburn (1995) has identified the different ways people diet:

(A) Avoiding eating - some people may eat very little or nothing at all between their binges (they fast). A common fasting pattern is avoiding eating all day, and then eat in the evening. About one in four bulimics do this.

(B) Restricting the overall amount eaten - usually this involves trying to keep food intake down to a certain kilijoule or calorie level. For many bulimics, this level is set well below the minimum daily requirements needed for normal functioning.

(C) Avoiding certain foods - people may often completely avoid foods they see as fattening or foods they think will trigger a binge. This relates back to the all or nothing thinking pattern, of viewing foods as 'good' or 'bad'. About 75% of bulimics diet in this way. Avoiding foods has the effect of increasing desire for it, thus setting you up to `fold' and eat large quantities of forbidden food, in a binge.

(D) Dieting in disguise - as a result of recent media backlash against dieting, it has become slightly unfashionable to 'be on a diet' these days. Some may describe that they are engaging in 'healthy eating', or may justify their food choices by stating that they are food intolerant or vegetarian. However it is rationalised or justified, any food restriction with the primary motivation of changing your size or body shape should be viewed as a diet.

The problem with dieting is that it becomes a vicious circle. It's one of the main factors that can trigger binge eating. Psychologically, dieting has the effect of increasing preoccupation with food and eating. It's not hard to see how preoccupation with food and eating can set you up to binge. Strict dieting inevitably leads to `failure'. This is demoralising, and tends to encourage binge eating. Typically, dieters who `fail' in their diet `give up' and binge. This reaction to breaking diet rules is another example of how all or nothing thinking patterns play a role in maintaining bulimia. Eliminating the `diet' mentality is a major aim of cognitive behaviour therapy for bulimia.

Physical Dangers Associated with Bulimia

Bulimic behaviours such as binge eating, vomiting, and laxative and diuretic abuse, have serious health consequences. Many people are not aware of the serious effects bulimic behaviour can have.

Consequences of binge-eating/vomiting

  • Sore throat
  • Sinus infections
  • Rupture of stomach or oesophagus; haemorrhage, peritonitis and death
  • Swollen glands beneath the jaw
  • Loss of dental enamel
  • Deterioration of gums
  • Dehydration and fainting spells
  • Indigestion and ulcers
  • Acid/alkaline imbalances
  • Hiatal and other hernias
  • Irregular or absent menstrual periods
  • Possible infertility
  • Endocrine imbalances
  • Muscle spasms and seizures
  • Electrolyte imbalances especially potassium loss, which can lead to irregular heartbeat and cardiac arrest
  • Urinary tract infections
  • Blood sugar fluctuations which in turn can cause clammy hands, tremors, blurred vision, anxiety, and heart palpitations
  • Puffy skin under the eyes
  • Broken blood vessels in the face
  • Bruises and scars on the fingers (teeth marks from pushing food into the mouth).

Consequences of Laxative and Enema abuse

  • Dependency
  • Loss of protective intestinal mucous thus making the bowel vulnerable to infection
  • Loss of muscle tone in the bowel, which then becomes a flaccid sack that collects and retains large amounts of faecal material
  • Dehydration, tremors, weakness, and fainting spells
  • Electrolyte imbalances, especially potassium loss, which can cause irregular heartbeat, heart attack, and death
  • Rectal bleeding
  • Irritable bowel syndrome (painful abdominal swelling, and constipation or diarrhoea)
  • Bowel tumours (some are benign but others are cancerous).

Laxative and enema dependency can usually be overcome, although medical supervision is recommended. Tapering off is far wiser than stopping 'cold turkey'.

Consequences of Diuretic Abuse

  • Diuretics ('water pills') can cause permanent, irreversible kidney damage. If one becomes dependent on these pills, withdrawal may result in water retention.
  • Diuretics can also cause dehydration, muscle weakness, and fainting spells.
  • They can lower the level of potassium and other electrolytes in the body, causing irregular heartbeat, heart attack, or even death.
  • Diuretics can cause a dry mouth, a coated tongue, and cracked lips.

Medical supervision is recommended to help individuals wean themselves off water pills. Electrolytes should be monitored regularly, and tests should be run to determine whether or not kidney damage has occurred.

Medical literature continues to report new links between bulimia and a multitude of physical problems. Medical evaluation, treatment , and monitoring of bulimic patients is strongly recommended for the prevention of further problems and possibly death.

CBT Treatment for Bulimia

Cognitive behaviour therapy (CBT) was the first promising treatment for bulimia (Fairburn, 1981), and it is the most extensively studied of the psychological treatments for bulimia. On the basis of research findings, CBT is generally regarded as the treatment of choice for bulimia. CBT has been compared in the research to other forms of treatments, including supportive psychotherapy, focussed psychotherapy, exposure plus response prevention, behaviour therapy, and treatment with antidepressant drugs. CBT has been found superior to all of these treatments (Fairburn, 1993). Overall, people treated with CBT experience substantial improvement. Moreover, these improvements are well maintained, at least over the first twelve months following treatment. Further research of longer-term maintenance of treatment gains is needed (Fairburn, 1993).

CBT treatment of bulimia generally includes the following:

  • Assessment
  • Education about the cognitive view of how bulimia is maintained, and the need for cognitive and behavioural change
  • Education about body weight regulation, adverse effects of dieting, and the physical impact of binge eating, self-induced vomiting, and laxative or diuretic abuse
  • Introducing self-monitoring of food intake and binge behaviour
  • Introducing a pattern of regular eating (this may include seeing a dietician)
  • Alternative behaviours to binge eating
  • Dealing with strong feelings without binging
  • Eliminating dieting using behavioural and cognitive techniques
  • Identifying cognitive distortions about dieting, food, body image, and self esteem
  • Challenging and changing cognitive distortions using cognitive techniques
  • Behavioural experiments deigned to test and challenge rigidly held beliefs which maintain bulimia
  • Teaching problem solving skills
  • Addressing body image concerns
  • Relapse prevention planning

At Treat Yourself Well Sydney, we complement our CBT treatments for bulimia with a range of Mindfulness and Acceptance & Commitment Therapy (ACT) techniques. Mindfulness and ACT are relatively new psychological therapies, which are showing a great deal of promise as effective adjuncts to the treatment of eating issues. Mindfulness techniques help people to develop an awareness of their body's hunger and fullness signals, something which many bulimic people are out of touch with. ACT principles help people to overcome the relentless negative self judgements associated with bulimia, to develop self compassion and values based living.

As you can see, our treatment approach goes much further than tackling just food-related bulimic behaviour (bingeing and purging), helping people to change the drivers and maintainers of bulimia. You can beat this for good!

If you are interested in learning more about CBT for bulimia, give us a call at Treat Yourself Well Sydney on (02) 9555 4810 or send an email to essentials@self.net.au. All of our psychologists have an expertise in treating bulimia. Why not speak to someone today?

 
logo

Psychology for a Healthy Mind and Body


To enquire please call (02) 9555 4810
or email essentials@self.net.au