Bulimia nervosa: symptoms, diagnosis and treatment

By Cristiano Antonino On Mar 11, 2023

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According to the new DSM 5 classification (Diagnostic and Statistical Manual of Mental Disorders, 2013) bulimia nervosa falls under the diagnostic category of nutrition and eating disorders

Bulimia nervosa, the symptoms

All of the following characteristics must be present for a diagnosis of bulimia nervosa to be made:

Recurrent binges characterised by the consumption of large amounts of food and the feeling of losing control over the act of eating.
Recurrent inappropriate compensatory behaviour to prevent weight gain. Many people use self-induced vomiting, others resort to laxatives, diuretics or strenuous exercise sessions.
Binge eating and compensatory behaviour should occur on average at least once a week for three months.
Self-esteem levels are strongly influenced by weight and body shape

Bulimia phenomena do not occur exclusively during episodes of anorexia nervosa.

Other symptoms and characteristics of the disorder

Individuals with bulimia nervosa typically feel ashamed of their pathological eating habits and try to hide them.

Bulimic crises occur in solitude: as secretly as possible.

The episode may be more or less planned, and is usually characterised (although not always) by the rapidity of food ingestion.

The binge often continues until the bulimic individual feels ‘so full as to be sick’.

It is precipitated by states of negative mood, interpersonal conditions of stress, intense hunger following dietary restriction.

Or from feelings of dissatisfaction related to weight, body shape or food.

A bout of bulimia is also accompanied by feelings of losing control.

The loss of control associated with binge eating, however, is not absolute.

The bulimic subject may continue the binge in spite of the ringing telephone, but stop it abruptly if a spouse or roommate unexpectedly enters the room.

Another essential characteristic of bulimia nervosa is the frequent use of inappropriate compensatory behaviour to prevent weight gain, neutralising the effects of binge eating.

Among the methods, the most frequently adopted is the self-induction of vomiting, one of the most typical symptoms of bulimia.

Vomiting reduces the feeling of physical discomfort, as well as the fear of gaining weight.

In some cases, vomiting is the desired effect. The person suffering from bulimia binges in order to vomit, or vomits even small amounts of food.

Generally, in the advanced stages of the disorder these individuals are able to vomit on command.

Other elimination behaviour of bulimic patients is the inappropriate use of laxatives and diuretics.

The use of laxatives is present in one-third of individuals who present with the symptoms of bulimia nervosa.

Rarely, the use of enemas immediately after binge eating is also present, but it is never the only elimination behaviour.

Other compensatory measures for binge eating are fasting on the following days or excessive exercise.

Thyroid hormones are rarely used to speed up the metabolism and prevent weight gain.

Side effects of self-induced vomiting

The frequent use of elimination behaviours typical of bulimia nervosa can produce alterations in electrolyte and fluid balance.

Among the most frequent are:

hypokalemia,
hyponatriemia,
hypokalemia.

Loss of acid gastric juice through vomiting can produce metabolic alkalosis (increased serum bicarbonate).

Abuse of laxatives to induce diarrhoea may instead cause metabolic acidosis.

Some individuals with symptoms of bulimia nervosa show a slight elevation of serum amylase.

This is probably related to the increase in salivary isoenzyme.

Repeated vomiting can lead to conspicuous and permanent loss of tooth enamel, especially at the lingual surfaces of the incisors.

These teeth become chipped, notched, and ‘moth-eaten’.

There may also be an increase in the frequency of caries.

In some individuals the salivary glands, especially the parotids, may become markedly enlarged.

Causes of bulimia nervosa and maintenance factors

The disorder is self-perpetuating.

That is, it consists of a mechanism with numerous elements that, in addition to being direct expressions of the disorder, are maintenance factors.

People suffering from bulimia nervosa judge themselves predominantly in terms of controlling their eating, weight and body shape.

The direct consequence of the preoccupation with body shape and weight is to adopt rigid and extreme dietary rules.

Such rules require constant effort to be followed strictly and are the main factor responsible for the onset of binge eating.

Following a strict diet in a perfectionistic manner inevitably leads sooner or later to minor transgressions.

These are experienced by those suffering from eating disorders as an irreparable loss of control.

Binge eating may initially give pleasure because it relieves the tension of having to follow the diet rigidly.

As time passes, however, they trigger negative emotions (fear of gaining weight, guilt, shame, disgust) which in turn can trigger new binges.

They thus feed the vicious circle that maintains the symptoms of bulimia.

Treatment of bulimia nervosa

Psychotherapy for bulimia nervosa

All evidence-based (i.e. scientifically proven effective) treatments for bulimia nervosa are psychological in nature.

At present, research shows that cognitive behavioural therapy CBT-E is the best treatment choice for bulimia.

CBT-E (enhanced cognitive behavioural therapy) is a specific form of cognitive behavioural therapy focused on the psychopathology of eating disorders.

It was developed at Oxford University by Christopher Fairburn and has rapidly spread around the world as a first-choice treatment.

This form of psychotherapy addresses the specific psychopathology of the eating disorder and the processes that maintain it, through the use of specific strategies and tools.

There are four phases to the treatment:

Phase 1. Preparation for treatment and change. Work begins on concerns about weight and food through specific strategies.
Phase 2. In this phase, we take stock of the progress made in phase 1 and plan the goals for phase 3.
Phase 3. It involves working on different modules (body image module, cognitive diet restriction module, mental states module…)
Phase 4. Aims to minimise the risk of relapse.

Medications for bulimia nervosa

The drugs that are most commonly used in the treatment of bulimia are antidepressants belonging to the selective serotonin reuptake inhibitor (SSRI) category.

However, it must be emphasised that recent research indicates that in many individuals the drug has no long-term efficacy.

The use of antidepressant drugs in the treatment of bulimia can be effective for three main reasons:

it allows an average reduction of 50-60% in the frequency of binges within a few weeks;
it allows an equivalent reduction in the frequency of vomiting, an improvement in mood and sense of control over eating and a decrease in preoccupation with food;
the antidepressant effect of the drug occurs in both depressed and non-depressed subjects.

It appears, however, that although the antidepressant drug succeeds in reducing binge eating, it cannot eliminate specific factors that contribute to the maintenance of bulimia nervosa, such as strict dieting.

Bibliographical references

In Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press. (Transl. it. Cognitive behavioural therapy of eating disorders, Trento: Erikcson, 2018).

Dalle Grave, R. (2013). Multistep cognitive behavioral therapy for eating disorders: Theory, practice and clinical cases. New York: Jason Aronson (Transl. it. Multistep cognitive behavioural therapy for eating disorders, Trento: Erikcson, 2018).

Dalle Grave, R. (2016). How to overcome eating disorders. A programme based on cognitive behavioural therapy. Verona: Positive Press.

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