Bulimia nervosa

The typical symptoms of bulimia nervosa include:

Psychological and Behavioral Symptoms

• Being obsessive about food and weight
• Fear of gaining weight
• Eating large amounts of food at once
• Loss of control during eating
• Trying to lose weight by vomiting, exercising, dietary supplements, herbal products, or fasting after overeating
• Restricting calories between binge eating
• Self-induced vomiting
• Peculiar eating habits or rituals
• Inappropriate use of laxatives or diuretics
• Irregular or absent menstruation
• Anxiety
• Depression
• Low self-esteem
• Feelings of helplessness
• Intense unhappiness with body shape and size

Physical Symptoms

• Sore throat
• Tiredness
• Dental problems due to erosion of enamel from vomiting
• Swollen cheeks or jawline
• Constipation
• Acid reflux
• Dehydration

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The exact cause of bulimia nervosa is not known. However, various causes that are thought to trigger bulimia are discussed below:

Biological Causes

• Genetics: Genetics plays a significant role in the development of eating disorders like bulimia nervosa. One bulimia susceptibility gene is linked to the short arm of chromosome 10. Another gene is thought to be located on chromosome 14. Studies supporting this theory suggest that twin siblings have a 50% chance of developing an eating disorder if the other twin has the disease.
• Neurobiology: Serotonin is a neurotransmitter that affects appetite and mood. Low levels of serotonin in some individuals can trigger eating disorders such as bulimia. These altered serotonin levels can lead to disturbed mood and binge eating.

Psychological Factors

The desire for a perfect body can predispose individuals to develop bulimia nervosa.

Socio-Cultural Factors

Cultural preferences for being lean, influenced by social media and other factors that portray a slim body as an ideal, can also contribute to the onset of bulimia nervosa.

• Age: The likelihood of developing bulimia nervosa is higher during the teenage years due to societal pressures related to body image.
• Gender: This eating disorder predominantly affects females compared to males. Teen girls aged 15 to 19 years are at an increased risk of developing this disorder.
• Family History: Individuals with bulimia are more likely to have a family history of eating disorders, physical illnesses, and other mental health issues. Conditions such as substance abuse, anxiety disorders, and mood disorders are also prevalent among those with bulimia.
• Early Menarche: The early onset of menstruation can trigger bulimia nervosa due to the associated sexual development and increased need for attention. This can also lead to a higher deposition of adipose tissue, resulting in body dissatisfaction and triggering bulimia nervosa.
• Obesity: Individuals who are obese often face pressure from family and peers to lose weight, which can trigger symptoms of bulimia nervosa. Increased body weight may also exacerbate other risk factors for bulimia.
• Dieting: Prolonged excessive calorie restriction can have negative effects, leading to binge eating and purging behaviors. Notably, bulimia is commonly observed among models and actors in the fashion and entertainment industries, where there is a strong obsession with maintaining a perfect body. Studies indicate that approximately 40% of models engage in some form of eating disorder, and 25% reportedly use self-induced vomiting as a method to prevent weight gain.

DSM-5 Guidelines

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following diagnostic criteria for diagnosing bulimia nervosa:

• Recurrent episodes of binge eating characterized by both of the following:
• Eating, in a discrete period of time (e.g., within a two-hour period)
• Lack of control over eating during the episode
• Inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, other medications, fasting, or excessive exercise.
• Both of the above episodes occur at least once a week for three months.
• Self-evaluation is influenced by body shape and weight.
• Bingeing or purging does not occur exclusively during episodes of behavior typical of anorexia nervosa.

There is no definitive test to diagnose bulimia nervosa. However, several tests are performed to assess the impact of the disease on overall health:

Physical Exam

This includes assessment of height, weight, and vital signs such as heart rate, blood pressure, and temperature. Skin and nails are also examined.

Lab Tests

While lab tests do not confirm bulimia, they are useful in identifying underlying health issues. Common lab tests include:

• Complete blood count (CBC)
• Serum electrolyte test
• Thyroid test
• Liver function test
• Kidney function test
• Urinalysis

Psychological Evaluation

This involves an assessment of thoughts, feelings, and eating habits by a therapist or mental health provider. It may also include completing a psychological self-assessment questionnaire.

Imaging Studies

• X-rays: These are performed to measure bone density and assess any stress fractures.
• Electrocardiogram (ECG): Self-induced vomiting in bulimia can lead to hypokalemia (low potassium levels in the blood), which may cause heart problems such as arrhythmias (irregular heartbeat). An ECG is conducted to evaluate heart activity and function.

There is no sure way to prevent bulimia nervosa because it is affected by several factors. However, the following factors may help in reducing the risk of bulimia:

• Adhering to lifestyle guidelines such as eating on time, consuming a balanced diet, and exercising regularly. Sound and adequate sleep also plays a pivotal role in maintaining overall health.
• Developing a healthy attitude towards eating.
• Having a positive attitude towards body size and shape.
• Education and awareness about bulimia nervosa.
• Early treatment in case of any suspicion.
• Balancing work, social life, adequate rest, and exercise.
• Maintaining sound mental health.

The primary goal of therapy is to inhibit the two key symptoms of bulimia nervosa, which are binge eating and purging.

Pharmacotherapy

Anti-depression Medications

These medications have shown to ease symptoms of bulimia nervosa, including reducing the frequency of binge eating and vomiting episodes. Some examples include:

• Fluoxetine
• Citalopram
• Sertraline
• Trazodone

Anti-epileptic Medications

These medications, such as topiramate, have shown a reduction in binge episodes. However, the side effects, especially weight loss and cognitive problems, should be carefully monitored while using this medication.

Treatment of Associated Symptoms

Treatment of Dehydration

Bulimia nervosa can lead to dehydration, for which medical intervention such as saline administration is indicated to compensate for the lost fluid.

Treatment of Constipation

Constipation is very common in bulimia nervosa. The treatment includes hydration, exercise, and the use of dietary fiber. In severe cases, low doses of polyethylene glycol and lactulose are used.

Psychotherapy

Psychotherapy helps the patient understand the issue better and how to cope with it. The various types include:

• Family-based therapy (FBT): Also called the Maudsley method, it engages parents/family in the process of restoring the patient to a healthy weight at home.
• Cognitive behavior therapy (CBT): This therapy aims to improve mental health, with a primary focus on addressing distorted views of self-body image.
• Dialectical behavior therapy (DBT): This therapy aims to recognize triggers and methods to manage factors causing bulimia nervosa. DBT also helps patients manage their mental health balance.
• Acceptance and commitment therapy: This therapy aims to develop self-motivation rather than changing thoughts and feelings.
• Interpersonal therapy (IPT): This therapy helps patients recognize and solve problems in their relationships. Improving relationships and mental health has been found to reduce eating disorder symptoms.
• Nutrition counseling: Counseling with a nutritionist can help you understand the importance of diet and restore normal eating patterns.

Nutritional Planning

The effective management of bulimia nervosa requires conscious eating through understanding calorie intake and dietary needs. Keep a record of what you are eating. A well-balanced nutritional plan helps in overcoming impulsive binge eating and purging. It is crucial to make informed food choices and develop healthy eating habits.

Yoga

Patients with bulimia nervosa often experience a lack of physical and mental control over their actions and self-image. Yoga is an excellent tool for relieving mental stress and controlling behavioral symptoms. It emphasizes holistic improvement of the mind, body, and soul. Here are some health benefits of yoga:

• Reduces stress and anxiety
• Improves body awareness
• Enhances self-esteem
• Promotes emotional stability

Meditation

Meditation aids in calming the mind and focusing on the inner self. It has been shown to improve self-image and reduce impulsive behaviors such as binge eating.

Emotional Self-Care

Low self-esteem is a significant risk factor for bulimia nervosa. Self-care includes consistently reminding yourself that you are a good and beautiful person, engaging in activities you love, and reflecting on moments of success. This can help in managing mood swings and depression. Being happy and healthy starts with small, everyday habits, and trying some of these can make a substantial difference in your life.

Most of the complications associated with bulimia nervosa are linked to the method used by the patient to eliminate foods from the body. Excessive vomiting and overuse of laxatives can also severely affect the digestive system. Various complications affecting different body parts are discussed below:

Skin, Hair, and Nails

Most of these complications start to appear when body mass index (BMI) drops below 16. The complications include:

• Hair loss
• Dry skin
• Rapid growth of excessive hair, especially on the face
• Swelling of the lips
• Orange discoloration of the skin due to excess carotene in the sweat
• Fragile nails

Individuals with bulimia may develop Russell’s sign due to mechanically inserting the fingers into the mouth to induce vomiting. This sign refers to the abrasions on the back of the hand developed due to repetitive exposure to the mouth.

Eyes and Nose

The repetitive act of self-induced vomiting can cause red patches inside the white (conjunctiva) of the eye. Patients may also experience repeated episodes of nosebleeds due to purging.

Dental

The act of self-induced vomiting exposes the oral cavity to gastric acid, leading to several dental complications. Dental erosions are usually noticed after six months of regular self-induced vomiting. Bingeing on high carbohydrate content food and carbonated beverages can also lead to dental caries. Other dental complications that can develop over time include:

• Increased tooth sensitivity
• Xerostomia (dry mouth)
• Gingivitis (inflammation of the gums)
• Gum irritation
• Gum bleeding
• Sialadenosis (salivary gland hypertrophy)

Throat

The repeated exposure of acidic contents to the vocal cords and surrounding areas can lead to:

• Hoarseness in the voice
• Difficulty in swallowing
• Chronic cough
• Burning sensation in the throat
• Repeated sore throat

Gastrointestinal

Repeated vomiting can lead to several gastrointestinal complications that include:

• Esophagitis
• Esophageal erosions
• Esophageal ulcers
• Barrett’s esophagus (change in the mucosal lining of the esophagus)
• Gastrointestinal bleeding

Boerhaave’s syndrome (esophageal rupture) is a rare complication of bulimia nervosa. The syndrome is characterized by chest pain and shortness of breath. Painful yawning can also be seen in patients who have tachycardia (increased heart rate).

Cardiac

Dehydration due to vomiting can cause various cardiac complications. The excessive loss of electrolytes in vomiting can lead to hypokalemia, which is low potassium levels that negatively affect the heart. Some of the cardiac complications include:

• Sinus tachycardia (electrical signals from the heart’s sinoatrial (SA) node make the heart beat faster than normal)
• Low blood pressure
• Orthostasis (low blood pressure while standing)

The use of ipecac as an inducer for vomiting can also lead to several life-threatening complications, which include:

• Ventricular arrhythmias (irregular heartbeats that can lead to syncope and palpitations)
• Congestive heart failure
• Cardiac death

Lungs

In patients who purge via self-induced vomiting, the following complications may develop:

• Aspiration of regurgitated food (inhalation of gastric content into the airway)
• Pneumomediastinum (presence of air in the space in the chest between the two lungs)

Home Remedies

• Aloe Vera: The binge eating and self-induced vomiting in bulimia nervosa deprives the body of appropriate nutrition. It also causes bloating, which makes the patient more concerned about their body shape. Aloe vera soothes the stomach and helps reduce bloating.
• Probiotics: Bulimia nervosa causes a loss of beneficial bacteria that the body needs to maintain good gut health. Probiotics heal the digestive system and help cultivate good bacteria, increasing the body's nutrient intake efficiency.
• Ginseng: It stimulates appetite and boosts mood. It has also been shown to relieve anxiety and depression closely associated with bulimia nervosa.
• Orange (Santra): An excellent source of Vitamin C that helps fight infections due to low immunity. Oranges also stimulate appetite and help reduce the desire to binge eat.
• Spinach (Palak): A good source of folic acid that has been shown to reduce depression. It also helps rebuild the health of the digestive system.
• Salmon: This fish is high in omega-3 fatty acids, which help reduce anxiety and stabilize mood. It also aids in balancing the body's metabolism.

Bulimia nervosa is a mental disorder that affects one’s body, mind, and soul. Living with bulimia nervosa can be challenging, as individuals often experience dissatisfaction with their body image. Along with pharmacotherapy and conscious eating, the following tips may assist patients in their recovery:

• Focus on your therapy.
• Take medications as directed.
• Eat when hungry, and stop when full.
• Appreciate your body.
• Say “no” to diets.
• Seek nutritional counseling to learn about healthy eating.
• Practice yoga and meditation.
• Be open and honest about your recovery.
• Be aware of the risk of relapse.
• Engage in activities that bring you joy.
• Participate in hobbies such as gardening or painting when the urge to binge is strong.
• Join support groups.
• Build a strong support system with your parents, partner, or friends.
• Ensure you get enough sleep.