Bulimia Nervosa


What is Bulimia Nervosa?

Bulimia Nervosa is an eating disorder characterized by episodes of binge eating followed by compensatory behaviors to avoid weight gain due to the binge behavior. Simply put, compensatory behaviors can include self-induced vomiting, the abuse of laxatives or diuretics, and overexercise, to name a few.

Binge eating

In the context of bulimia nervosa, the individual may experience a sense of loss of self control during episodes of binge eating. Binge eating is less about a particular number of calories or amount of food, and more about an intentionally large amount of food in a short time. Individuals suffering from bulimia nervosa will typically engage in binge eating and purging in isolation. Hiding such behaviors is quite common as the person suffering from bulimia may fear that others will stop them if they notice.

Compensatory Behaviors / Purging

Many people think of bulimia nervosa as purging through self-induced vomiting. While this is the most common method of compensating for binge eating, individuals suffering from bulimia may engage in the abuse of laxatives, diuretics, or engage in overexercise. The abuse of over the counter laxatives/ diuretics can be highly dangerous as their effect on the GI track can be irreversible in cases of severe, prolonged abuse. 

Medical Issues Associated with Bulimia Nervosa

There are many medical problems that are present for individuals suffering from bulimia nervosa. A list of several are included below.

Dental Problems 

Self-induced vomiting common in bulimia nervosa draws acid from the stomach to the mouth. This results in significant erosion of tooth enamel and the health of the tooth overall. 

Heart Problems

Various heart problems including arrhythmia or even heart failure may result from self-induced vomiting or other compensatory behaviors present in bulimia nervosa. Such behaviors can result in significant electrolyte imbalances. Low potassium, in particular, is often the result of purging behaviors and can result in heart issues and even death.

Dehydration

While many think of dehydration as not a big deal, it can actually be quite serious in individuals suffering from bulimia. Resultant kidney problems and fainting may occur. Considering that fainting can be dangerous (hitting head on floor, etc.) and can occur anytime (including when operating a motor vehicle), such problems associated with bulimia nervosa should be taken very seriously.

Gastrointestinal Issues

The longterm abuse of laxatives that is present in many individuals suffering from bulimia nervosa can result in permanent problems including having portions of the GI track removed (e.g. colon) and 

Damage to Esophagus 

Frequent purging in bulimia nervosa can result in tears in the esophagus or even, in severe cases, rupturing of the esophagus. 

Treatment of Bulimia Nervosa

The treatment of bulimia nervosa may involve several different levels of care depending on the severity of the disorder. I will describe each level of care briefly below. I will then discuss several therapeutic modalities for the treatment of bulimia nervosa, many of which may take place at all levels of care.

It is important to note that many individuals suffering from bulimia may want to choose a higher level of care where they may be able to continue their life as usual. However it is key to distinguish between optimism and denial. The goal should be recovery first and foremost, even if it means a higher level of care and a disruption of one's normal day to day life. If you are considering an appropriate level of care, please consult with an eating disorder professional who may be able to speak to your particular story objectively. 

One of the main goals of the treatment of bulimia nervosa is behavior interruption. It is important to interrupt the binge-purge cycle to help stabilize the behavior and the person's lifestyle. 

Inpatient Treatment

Inpatient treatment for bulimia nervosa is indicated when there are acute medical issues that need to be resolved. Some of these medical issues were discussed above and may need immediate care. Often these issues may result in a person with bulimia nervosa seeking assistance at an emergency room. Admission to a medical hospital for 1-3+ days may be needed to stabilize the individual. Following this, other levels of care described below, or treatment in an eating disorder program at an inpatient psychiatric hospital may be recommended.

Residential Treatment

Residential treatment for bulimia nervosa is often held within home like environments. Treatment is 24/7 for 1-3 months and includes individual therapy, group therapy, family therapy, dietary counseling, medical monitoring, and medication management (if indicated). Medical monitoring tends to be somewhat intensive as many individuals with bulimia nervosa in this level of care have active medical issues that need to be resolved.

Partial Hospitalization Program (PHP)

This level of care typically takes place for 15-30 hours per week (depending on the program and state regulations) and may include 3-6 days of treatment per week. Treatment for bulimia nervosa in PHP likely includes at least 2 meals per day and may, for example, run from 8:00am-2:00pm several days a week. Treatment typically includes individual therapy, dietary counseling, medical monitoring, group therapy, family therapy, and medication management (if indicated). While many of the treatment modalities are the same as residential treatment, the intensity and monitoring is significantly less.

Intensive Outpatient Program (IOP)

Individuals suffering from bulimia nervosa in the IOP level of care may attend and participate in treatment in an eating disorder specific IOP 3-4 evenings per week for 3+ hours each evening. Treatment in this setting typically involves a supervised meal and meal process group / group therapy. Typically individual therapy and dietary counseling are either limited or on the client's own time (with his/her outpatient team). 

Outpatient

Outpatient therapy for bulimia nervosa typically involves meeting with a therapist 1x weekly, a dietitian 1-2x monthly, a medical doctor 1x monthly, and a psychiatrist (if indicated). Depending on severity in the outpatient level of care, sessions may be more or less frequent. 

Therapeutic Modalities for Bulimia Nervosa

Below I will describe two research supported treatments for bulimia nervosa. Please note that both of these treatment modalities are likely present in all levels of care of bulimia nervosa described above. Also, it is important at all levels of care that one work with a therapist, dietitian, medical doctor, and psychiatrist (if indicated) during the process of treatment for bulimia nervosa. The below modalities are therapeutic orientations that your therapist may take in helping you toward recovery from bulimia.

Cognitive Behavioral Therapy (CBT)

Generally considered the most effective treatment, CBT is often used to treat individuals suffering from bulimia nervosa. In the treatment of bulimia nervosa with CBT, the goal is to increase awareness as to triggers to binge-purge behaviors, identify and challenge thoughts, feelings, and assumptions that serve to maintain the bulimia in the person's life, and to empower the individual to develop positive coping strategies. 

Interpersonal Psychotherapy (IPT)

IPT focuses on relational problems the individual suffering from bulimia nervosa may encounter in their life that serves as a stressor. The goal, set with the client, is to interrupt urges to binge and purge that may come from poor interpersonal relationships, isolation, or communication difficulties in relationships. Thee focus is also to help the individual identify and implement coping skills to cope with urges to binge and purge that are highly present in individuals suffering from bulimia nervosa. Lastly, relapse prevention is discussed once the person has made substantial progress and is no longer engaging in binge-purge behaviors.