Bulimia Nervosa and Co-Occurring Mental Health Disorders

Contributor:  Carolyn Labrie, MPH, PhD(c), for Center for Discovery

Bulimia nervosa is an eating disorder that, according to the National Eating Disorders Association, affects 1-2% of adolescent and young adult women. Characterized by the consumption of large amounts of food in binge episodes, and subsequent compensatory behaviors such as purging or use of laxatives, bulimia can have serious, life-threatening consequences. People with bulimia often remain at an average weight and become very good at hiding their behaviors, making it difficult for family, friends, or medical professionals to recognize a problem. Adding to the serious nature of this eating disorder are the co-occurring issues that can come along with it- specifically, anxiety, depression, self-harm, and substance abuse.

The Development and Progression of Bulimia

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) sets forth specific criteria for the diagnosis of bulimia:

  • Eating an amount of food that is significantly more than most people would eat in a similar period of time (e.g. 2 hours) under similar circumstances
  • A feeling that one cannot control what is being eaten or stop eating

Further characterizing bulimia are the compensatory behaviors engaged in to offset the binge cycle:

  • Vomiting
  • Laxative, diuretic, or enema use
  • Fasting
  • Excessive exercise

How often the compensatory behaviors occur guides the determination of level of severity of the illness:

  • Mild: 1-3 inappropriate compensatory behaviors per week
  • Moderate: 4-7 inappropriate compensatory behaviors per week
  • 8-13 inappropriate compensatory behaviors per week
  • Extreme: 14 or more inappropriate compensatory behaviors per week

Bulimia often starts in adolescence and the secretive nature of the illness can cause it to go undetected for years. The longer the illness goes on, the higher the risk for serious medical complications, such as:

  • Electrolyte imbalances and cardiac events
  • Tooth decay
  • Inflammation or rupture of the esophagus
  • Bowel issues
  • Gastric rupture

Co-Occurring Mental Health Issues

What comes first: the eating disorder or co-occurring issues like depression and anxiety? Research shows that mood disorders and anxiety disorders are common among people who struggle with eating disorders. Changes in brain chemistry like serotonin can be at the heart of eating disorders and depression and anxiety. According to the Journal of Psychiatry and Neuroscience, these chemical changes can also be brought about by the behaviors that are the hallmarks of eating disorders: starvation and the binge/purge cycle can create imbalances that affect mood.

Having a mood disorder or anxiety issue like Obsessive-Compulsive Disorder can be a risk factor for developing an eating disorder. Someone who is struggling with bulimia may not recall any body image issues as a child but may remember certain ritualistic patterns and behaviors that eventually developed into the bulimia symptoms. At the same time, a person who has no history of anxiety or depression may develop bulimia as a coping mechanism for significant trauma or life changes.

Substance abuse and eating disorders co-occur significantly. Dual Diagnosis (www.dualdiagnosis.org) reports that many of the characteristics of substance abuse can also be seen in eating disorders like bulimia:

  • Risk factors like family history, abuse, brain chemistry
  • Intensity of symptoms during major life changes
  • History of low self-esteem, depression, and anxiety disorders
  • Compulsive behavior patterns
  • Preoccupation with food or substances
  • Chronic conditions that get worse with time and produce potentially life-threatening complications

Self-injury is also common in patients with bulimia. According to an article published on ABC News, a Stanford University study found that 41% of eating disorder patients reported cutting or burning themselves. Non-lethal behaviors like these provide a temporary escape from pain and anxiety- a numbing effect that many eating disorder patients seek from their food related behaviors.

Treating Bulimia and Co-Occurring Conditions Simultaneously

Most eating disorder treatment programs are equipped to treat co-occurring conditions like mood and anxiety disorders and substance abuse. Recognizing that these conditions are often present in the eating disorder patient’s history, treatment is adjusted to manage the eating disorder as well as the underlying emotional issues. Bulimia in particular requires significant attention to behavior modification using Cognitive Behavioral or Dialectical Behavior skills-based therapies. In addition to individual counseling, bulimia patients should also receive:

  • Family therapy
  • Group therapy
  • Substance abuse treatment, like detox, if indicated
  • Treatment with antidepressants or mood stabilizers
  • Alternative therapies like yoga or acupuncture
  • Nutritional services

Any suspicion of bulimia should be taken seriously by medical professionals and the patient should be referred for specialized screening and treatment. In this assessment, co-occurring issues can also be found that require treatment as a holistic approach.

References

  1. PsychCentral (2014). Bulimia Nervosa Symptoms. www.psychcentral.com
  2. National Eating Disorders Association. Bulimia Nervosa. www.nationaleatingdisorders.org
  3. Dual Diagnosis (2014). Eating Disorders. www.dualdiagnosis.org
  4. Carollo, K. (2010). Double Whammy: Eating Disorders, Self-Injury Linked, According to Study. www.abcnews.go.com

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders.  These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.  We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors.  If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on October 9, 2015. Published on EatingDisorderHope.com