Bulimia nervosa is a serious condition that involves a potentially devastating assault on the mind and the body. The cause of bulimia is unknown, but it’s likely to involve a number of factors which, separately, could touch any of us. What we know for certain is that it has nothing to do with courage, character or strength.

From the outside, or through the eyes of somebody who has never had any experience of bulimia, the act of binging then purging might seem to make no sense at all. As with so many of the confusing things that we humans do, the only things stopping it from making sense are the right pieces of information. Those pieces are always there – somewhere – and whether they lie in biology, physiology, history, or anything else that makes us who we are, the only thing standing in the way of a complete understanding is ‘enough’ information. New research around bulimia has helped move us towards this. 

What is bulimia?

Bulimia involves repeatedly eating unusually large amounts of food in a relatively short period of time (generally within about two hours). The binging comes with a sense of loss of control, and is immediately followed by feelings of guilt and shame. In response to these feelings, a person with bulimia will try to compensate for the overeating by vomiting, fasting, overexercising, or misusing laxatives or diuretics. 

What are the warning signs?

Bulimia can often stay well-hidden because it doesn’t always come with an obvious weight change. People with bulimia will tend to maintain a fairly average weight for their height. Sometimes they might be a little above or below average, but not to the extent that would cause the people close to them to be concerned. Having said this, if someone is struggling with bulimia, there will be signs. On their own, these signs might not necessarily mean bulimia. It’s the combination, intensity and duration of symptoms that tends to signal and warning. Many of the symptoms exist on a spectrum, but the clue that something isn’t right will come from the level of intrusion into relationships, work, school, study, and day to day life in general. Something becomes a problem when it starts causing problems. Here are some signs to watch out for.

Behavioural.

• Dieting (fasting, calorie counting, avoiding particular food groups such as fats or carbs);
• Evidence of binging (large amounts of food disappearing, lots of empty wrappers);
• Change in eating habits (eating in private, avoiding meals, uncomfortable eating around others, skipping meals);
• Food rituals (excessive chewing, insisting meals must be at a certain time, eating slowly, eating with a teaspoon, cutting food into small pieces and eating one piece at a time);
• Focus on food preparation and planning (shopping for food, planning, preparing and cooking meals, reading nutritional guides).
• Change in food preferences (e.g. avoiding foods that were once enjoyed; replacing meals with drinks);
• Focus on body shape and weight (weight-loss websites, dieting strategies, images of thin people)
• Disappears after eating, often to go to the bathroom;
• Evidence of vomiting, laxatives, diuretics, weight loss pills, appetite suppressants;
• Excessive use of mints, mouthwash, gum;
• Change in dress (e.g. baggy clothes)
• Change in exercise habits (e.g. exercising despite weather, illness, injury or fatigue, distressed if not able to exercise)
• Secretive around food (e.g. hiding food, eating in secret, saying they’ve eaten when they haven’t, saying they’ll eat later or that they aren’t hungry, secretly throwing out food);
• Hoarding food;
• Withdrawing from friends or usual activities;
• Mood swings;
• Repetitive or obsessive body checking (checking in mirror for any flaws, pinching waist or wrists to check body fat, weighing self).

Physical.

• Sudden or frequent change in weight (loss or gain). (Body weight may also be within normal range for height);
• Change in menstruation;
• Fainting or dizziness;
• Tired or lethargic;
• Signs of regular vomiting (swelling around cheeks or jaw, calluses on knuckles, bad breath; discoloured or stained teeth; enamel erosion, cavities);
• Sensitivity to the cold (feeling cold often, even when the temperature is warmer);
• Abnormal lab results (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate);
• Dry skin;
• Slower to heal from injuries or more frequent illnesses.

Psychological.

• Preoccupation with eating, food, weight;
• Anxiety or irritability at meal times;
• Rigid black and white thinking (foods are either ‘good’ or ‘bad’);
• Distorted body image (believing they are overweight when they are actually a healthy weight or underweight);
• Comfort eating (eating to deal with stress, anxiety, boredom or depression);
• Feelings of worthlessness, shame, guilt, self-loathing.

How does bulimia happen?

There is no simple explanation for the cause of bulimia. We humans are a beautiful and complex mix of so many elements – genetics, environment, upbringing, culture, history. It’s likely that a combination of all of these, or at least some of these, contribute to bulimia.

A review of the research found that social factors (such as media exposure, the pressure to be thin, and the expectation of thinness), personality traits (negative emotionality, perfectionism, and the tendency to act impulsively when distressed) were risk factors for developing the symptoms of eating disorders. These risk factors then seem to interact with genetic factors to increase the vulnerability to disordered eating.

The urge to eat becomes altered.

Appetite and the drive to eat come from a part of the brain called the hypothalamus. The urge to eat is instinctive. Our bodies and our brains are designed to motivate us towards food when we’re hungry, and to keep the nutrients inside us when we take them in. 

In people with bulimia though, the primal, powerful instincts to seek nutrition, and to keep the body nourished, are altered. Researchers have uncovered the neurological reason for this. In a study published in the journal Translational Psychiatry, researchers found that in people with bulimia (and anorexia), the powerful signals to eat that are sent out by the hypothalamus are overwhelmed by a different part of the brain, effectively shutting down the urge to eat. The pathways to the hypothalamus are found to be much weaker in people with bulimia, and the direction of information seems to travel the other way – rather than sending out signals to eat, the hypothalamus receives signals not to eat. This ultimately overrides the urge to eat.

According to the study, we humans are programmed from birth to like the taste of sweet (breast milk is half sugar and half fat). In people with an eating disorder the fear of gaining weight steers them away from sweet food. The researchers suggest that this avoidant behaviour, driven by the fear of gaining weight, could impact the taste-reward pathways in the brain and reduce the influence of the hypothalamus, making it easier to ignore the urge to eat.

But if the urge to eat is shut down, what makes people binge?

Binging is not about hunger. People who binge might be hungry, but the loss of control that comes with binging and the quick and vast intake of calories are driven by other powerful factors. New research published in Journal of Abnormal Psychology has shed light on what contributes to, and maintains, the binging part of the cycle. The research was conducted in women, though it is important to note that bulimia in men is an equally serious issue.

Stress is known to be a trigger for binge eating in people with bulimia, but the research has found that the response to food after stress seems to differ between people with bulimia and those without. The researchers found that women with bulimia have a different brain reaction to images of food after stress, compared to the women without bulimia. Magnetic resonance imaging scans (MRIs) showed that following stress, when women without bulimia were shown pictures of food they had an increased blood flow to a part of the brain called the precuneus. This is a part of the brain associated with self-reflection. An increased blood flow to the region suggests that the person is engaged in self-reflection, rumination or self-criticism.

In women with bulimia however, blood flow to this part of the brain decreased. Following stress, the food cues seem to decrease the activity in the part of the brain involved in negative self-reflection or self-criticism.

The researchers believe that for people with bulimia, food shuts down self-criticism or negative thoughts about the self. Food seems to offer something else to focus on, other than emotional pain, and or anything about themselves which is a source of self-criticism or self-loathing.  

‘Our findings are consistent with the characterization of binge-eating as an escape from self-awareness and support the emotion regulation theories that suggest that women with bulimia shift away from self-awareness because of negative thoughts regarding performance or social comparisons and shift focus to a more concrete stimulus, such as food.’ – Brittany Collins, .

The results were replicated across two studies – a stressful activity increased feelings of stress, but activity in the part of the brain associated with negative thinking and self-criticism decreased when the women viewed food cues.

The food cues seemed to decrease self-reflection, but they also increased food craving. The relief that comes with binging might be short-lived, but in the moment, it’s something. The consequences of this are a catastrophic cycle of binging for relief, then purging to compensate for the overeating and the increased shame, guilt, self-criticism and negative thinking that comes with binging.

Recovering from bulimia.

Bulimia is tough, and the binge/purge cycle is a fierce one. At times it can seem so impossible to move through, but recovery is absolutely possible. It’s important to be aware that the healing process might take time. There may be many backwards steps along the way, and at times healing might seem hopeless, but the backward steps and stalls are all part of the healing process, not the end of it.

Research has found that after about nine years, almost 70% of people with bulimia will fully recovered, and stayed recovered over time.

“These findings challenge the notion that eating disorders are a life sentence … While the road to recovery is often long and winding, most people will ultimately get better. I’ve had patients say to me, ‘Food and my body are only parts of who I am now; neither defines me anymore,’ or ‘My life became more full, and there just wasn’t room on my plate anymore for the eating disorder.'” Kamryn Eddy, PhD, associate professor of Psychology in the Harvard Medical School Department of Psychiatry.

Where to go for support. 

Chances of long-term recovery seem to be greatly increased if the symptoms are changed in the early stages, so an early response is vital. If you or a loved one is struggling with bulimia, speak to a doctor or therapist. They’ll have the resources to find you the support you need, and will be able to refer to you a professional who specialises in eating disorders.

Recent research found that online group therapy was as effective as face to face therapy for bulimia (though a little slower to start with). The Butterfly Foundation for Eating Disorders is a wonderful organisation and they run a number of online support groups for people aged 16 and over who are working to recover from an eating disorder, as well as groups for carers, siblings and young carers. Find more information about their online support groups here. They also have an online chat for anyone who needs support or information (including carers).

(For a worldwide list of eating disorder support organisations (by country), see here.)

And finally …

Bulimia is a confusing, complicated illness that can have serious consequences, not only for the people who struggle with the illness, but also for the people who love them. Eating disorders are not a life sentence. The road through can be a difficult one, and requires the outside support of doctors and health professionals, but recovery is possible.

The most important thing for anyone struggling with an eating disorder is to reach out for support as soon as possible. Whether that support is from a doctor, a therapist, an online group, an online chat, or a trusted someone – any reach for help is a step out of the shadow and control of bulimia, and a step closer to healing. There is no shame in asking for help, and there is no need to know exactly what to ask for – that’s what professional support is for. We all have things we struggle with that we need extra help sometimes. The sooner the reach for support, the greater the chance of healing and reclaiming a strong, healthy, happy life.