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.
Thank you for this very educational and inspirational article on bulimia. My stepdaughter has recently been diagnosed. The family and herself are seeking out professional help. But it seems everyone (especially my husband, her Dad) is beating themselves up over how this could have happened. Thank you for this very informative read. I look forward to further reads on this subject.
This is a fascinating article, well-written, and detailed. Thanks so much for this important information, Karen. I’ll be sending it to my social media sites.
Thanks so much Jean.
Thanks for shedding some light on this rarely understood mental illness. The spectrum of disordered eating seems to be growing. I’d be interested in reading an article discussing other types of eating disorders, as well as an article dedicated to anorexia nervosa.
Great article! However, in the section on why people binge it refers in paragraph 2 and 3 to women without bulimia but I think one of the examples is meant to be talking about women WITH bulimia. Please could you take a look? Thanks. Sorry if it is me misreading it!
The articles reads correctly, but I understand your confusion. You would expect that the blood flow to the self-reflective part of the brain would be increased in people with bulimia, but the fascinating thing about this research is that it has found that food cues decreased the activity in the self-reflective part of the brain following stress. It’s normal following stress that we might reflect on what we might have done better, how we handled things, whether or not we coped ok etc. A little bit of self-reflection is healthy and normal. Of course sometimes this can come with negative thinking and criticism, but this tends to ease when the stress does. For women with bulimia, food seems to reduce this self-reflection, negative thinking, or self-criticism. This is how the binge/purge cycle becomes such a powerful one. Food is associated with a decrease the uncomfortable feelings that come with self-reflection or negative thinking. This is why the blood flow to the self-reflective part of the brain decreases (after stress) when there are food cues. Stress leads to self-reflection and self-critical thinking, but when food cues are introduced, this self-reflection and negative thinking decreases. I hope this makes sense. I’m grateful to you for raising the issue. It can seem counter-intuitive at first – you might expect self-criticism to be worse in people with bulimia – but it’s about why makes people continue to binge – food reduces activity in the precuneus which means that when there is food, there is also less self-reflection and less self-criticism.
I think the confusion the above reply is referring to is: under “But if the Urge to Eat is Shut Down…”
The second paragraph reads …”when women without bulimia were shown pictures of food they had an increased blood flow…”
The third paragraph reads… “In women without bulimia, however, blood flow to this part of the brain was decreased…”
Ahhh – I see the confusion. The third paragraph has a typo. It should read, ‘In women WITH bulimia …’ This has been amended in the text – thank you for pointing it out.
I suffered from Bulimia for over 20 years, from mid teens to my mid 30s. I thought it was going to kill me and I was never going to be free. For years I used willpower and other self soothing tools to help me recover but of course kept falling of the wagon and would find myself starting the cycle. It was with my then even when I was ok- like an alcoholic that is in recovery- always there; a possibility to relapse anytime. Then, in my late 30s, I trained as a Kundalini yoga teacher and developed my Pilates business. The esteem, confidence and clarity and connection I was developing finally changed me from recovering to recovered. Now it’s gone and I never binge and vomit or think about it. It’s just not part of my life anymore. Although the irony of having a job where my body is kept in shape is not lost on me and perhaps still figuring it out, I am no longer bulimic or worry about eating. I am free.
Laura thank you for sharing your story. I’m sure it will give hope to others. The power of ‘me too’ to heal is remarkable.
Was wondering if there was some kind of support group or some kind of way to talk to other people with this disease I have been struggling with this for about 8 years nobody knows and I do not know anybody else who does it I would really just like some support thank you
Vanessa I’ve just added this link to the article https://www.trichstop.com/. Hopefully you will find what you need here.
I’ve found i become bulimic when i am down and feel I have no control of where or what is happening in my life. I eat for the comfort, then feel like an even bigger looser, then can gain the control again by vomiting. It first started in my early 20’s when i was lost in life at University & struggling, then a guy i thought i wanted to be with told me i was too fat. Any relapse i’ve had since is when my self esteem is low and transition periods. I’m always surprised when it comes back, but am learning my own triggers now and try to control them.
Jane what you have said makes so much sense. You are NOT a loser! Don’t believe the words of anyone who makes you feel like you aren’t enough – including the words you use against yourself in your vulnerable times. You are so much more than enough and you always will be. Talk to yourself as you would a small child. There is a small child in all of us that needs love, protection, and someone to fight for us. Be that person for you. It sounds like you are well on your way to doing this – that takes strength, guts, wisdom and insight. Backward steps are part of the growth, not the end of it.
I struggled with bulimia in my twenties… after graduating from college and having NO idea how to function in my new expectations.
I am now retired from a successful career in education. i still look for answers to the “why” I got so caught up in this complicated behavior, but I did find help in a support group and a program at the U of MN. Your article, once again helped me to increase my understanding…much appreciated!
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karenyoung_heysigmund
Remember the power of ‘AND’.
As long as they are actually safe:
They can feel anxious AND do brave.
They can feel like they aren’t ready for brave, AND be ready brave.
They can wish to avoid AND they can stay (or not be taken home).
They can be angry, anxious, and push us away AND we can look after them through the feelings without avoiding the brave/ new, hard/ important.
We can wish for their anxiety, anger, sadness to be gone AND we can be with them without needing them to be different.
We can believe them (that they are anxious, scared, angry) AND believe in them (that they are capable).
When we hold their anxiety AND their capacity for brave, in equal measure and with compassion, we can show them that their anxiety doesn’t cancel their brave.♥️
Oct 7
karenyoung_heysigmund
These stickers or temporary tattoos are go anywhere cheerleaders for their brave - because being brave is hard sometimes! Available as packs of 12 individual tattoos or stickers.
Of course, tattoos and stickers are much handier if there is something special to hold them in. Oh, I hear you - and I’ve got you … enter the Hey Warrior tin to store them in (or treasure, or wishes, or snacks, or promises that they’ll clean their room - for especially big negotiations). Because truly - is there even such a thing as too much storage? No. Pffft. Of course not.
Now, of course, they’re all my favourites for equal amounts of time, but let me tell you about the hug tattoo and the hug sticker ...
These little stunners are for hugs on demand. If you’ve ever heard me speak about separation anxiety, you’ll know that one way we can ease it is to bring the idea of a child’s loved person closer. But how? Hug tattoos and hug stickers is how!
The idea is to load the hug tattoo or sticker with hugs - as many as they need to last all day, or lots of days, or until breakfast. Whenever they miss you, they can give their tattoo or sticker a squeeze and wrap themselves in one or forty of those hugs you’ve put in there.
They can also put their hugs in a tattoo or a sticker for you (or your phone, your water bottle - you get the idea). Remind them that whenever they think of you during the day, it’s because you’re using one of the hugs they’ve loaded up for you.
The hug tattoos and stickers have been tested and re-tested for ‘volume holdability’, and the conclusion, established through rigorous testing, (because non-rigorous testing would kind of make it a ‘guess’ which would be pointless), is that they can hold heaps of hugs, times a thousand, plus one - because when we’re talking about hugs there’s always room for one more, but I know you know that.
Available separately (12 pack of individual stickers; 12 pack of temporary tattoos; or the Hey Warrior tin) or save 20% with a bundle.♥️
Click on the link in the bio or here to buy or for more info https://www.heysigmund.com/shop/
Oct 7
karenyoung_heysigmund
Validation is a presence, not a speech.
It doesn’t mean you’re being permissive, or rewarding ‘bad’ behaviour. It doesn’t mean you’re saying the storm is okay. It’s a way of handling the storm and offering a safe passage through it, without judgement, shame, isolation.
Think about the times your big feels have taken over. Has it ever worked ever, in the history of forever, for someone to tell you to calm down, or shut you down, or manage you. Nope. Not for me either.
Because when we’re in big feels, we don’t need to be managed, we need to be seen. We don’t do or say the rubbish things we do because we don’t know the rules of social engagement, or because we haven’t had enough consequences, or because we think these things are okay. In fact, we’re not thinking at all. We do these things because in that moment, we don’t have the resources to do differently.
Validation is a way of adding resources, through relationship. It’s a strong, loving presence that sends the message, ‘Bring your feelings to me. I can take care of you through this. And I can keep you and everyone including you safe along the way.’
Of course even during a storm we need to hold boundaries to keep everyone safe (them, you, others), but let these be loving - hold the boundary, add warmth. ‘Yes, this is big. I want to hear you. (Relationship) No I won’t listen when you speak like that. When you can speak in a way I can hear, then we can talk (boundary). You’re not in trouble. I’m right here. (Relationship)
The might be a need for repair, learning, or talking about what’s happened, but during the storm isn’t that time.
We can’t reason with someone in big feels because the thinking brain, the part than can think rationally, logically, plan, think through consequences, make deliberate decisions, is locked out for a bit. This happens to all of us. It’s why we all do or say things that aren’t great when we’re in big feelings.
We can’t stop a storm once it’s storming, but we can offer a safe passage through it. This is what validation does. It a safe passage to a place of calm and connection, where you can have the influence and the conversations that will be growthful.♥️
Sep 26
karenyoung_heysigmund
The need for attention is instinctive.
We all need to be seen because that is how we stay safe. Attention is a need - a physiological, relational, instinctive need.
If attention is something we have to work for, or if it only happens when we’re ‘noticeable’ (as in demanding it, yelling for it, disappearing ourselves) our nervous systems will try to find a way back to safety by making ourselves visible. Brains would always rather be seen in a bad way, than not be seen at all - because being unseen is unsafe.
This isn’t a ‘kid’ thing. It’s a ‘human’ thing. Attention needing behaviour happens in our adult relationships too. If there isn’t enough play, joy, affection, we start to make ourselves noticeable. This might look like little verbal ‘swipes’, criticism, arguments, snaps. Ugh. We’ve all been there.
The mistake we’ve been making is tangling the need for attention with the need to be the centre of attention.
If a child’s behaviour is inviting (demanding?) attention, it’s because they are needing attention. The need is valid, even if the behaviour is a little (a lot?!) messy. All of us can struggle with niceties when our needs are screaming at us from the inside of us.
Of course you see them, love them, and would do anything for them. This isn’t about that - it’s about them feeling you enjoying them, seeking them out. It’s about them feeling the abundance of you - so much caring there are leftovers that they can tuck away for rainy days.
Sometimes of course there are just too many rainy days. Even as the most loving, attentive, devoted parents though, we get busy, distracted, stressed. That’s so okay and so normal! But it might mean our kiddos feel start to feel the absence of us a teeny bit. They won’t tell us they miss us. They’ll show us.
Of course we need to hold strong loving boundaries, but what can you add in to let them see that you enjoy them, miss them, like them.
Microconnections matter. Think of the difference it makes to you when someone shows you in teeny ways - a comment, a noticing, a seeking out of you - that they see you, even when they don’t have to. It’s oxygen.♥️
Sep 25
karenyoung_heysigmund
I love being a parent. I love it with every part of my being and more than I ever thought I could love anything. Honestly though, nothing has brought out my insecurities or vulnerabilities as much. This is so normal. Confusing, and normal.
However many children we have, and whatever age they are, each child and each new stage will bring something new for us to learn. It will always be this way.
Our children will each do life differently, and along the way we will need to adapt and bend ourselves around their path to light their way as best we can. But we won’t do this perfectly, because we can’t always know what mountains they’ll need to climb, or what dragons they’ll need to slay. We won’t always know what they’ll need, and we won’t always be able to give it. We don’t need to. But we’ll want to. Sometimes we’ll ache because of this and we’ll blame ourselves for not being ‘enough’. Sometimes we won’t. This is the vulnerability that comes with parenting.
We love them so much, and that never changes, but the way we feel about parenting might change a thousand times before breakfast. Parenting is tough. It’s worth every second - every second - but it’s tough.
Great parents can feel everything, and sometimes it can turn from moment to moment - loving, furious, resentful, compassionate, gentle, tough, joyful, selfish, confused and wise - all of it. Great parents can feel all of it.
Because parenting is pure joy, but not always. We are strong, nurturing, selfless, loving, but not always. Parents aren’t perfect. Love isn’t perfect. And it was meant to be. We’re raising humans - real ones, with feelings, who don’t need to be perfect, and wont need others to be perfect. Humans who can be kind to others, and to themselves first. But they will learn this from us.
Parenting is the role which needs us to be our most human, beautifully imperfect, flawed, vulnerable selves. Let’s not judge ourselves for our shortcomings and the imperfections, and the necessary human-ness of us.❤️
Sep 2
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