Bulimia – New Research Sheds Light on What Causes and Maintains the Binge/Purge Cycle

Bulimia - New Research Sheds Light what Causes and Maintains the BingePurge Cycle

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.

15 Comments

KP

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.

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Jean Tracy, MSS

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.

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Tammy

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.

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Kimberley

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!

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Karen Young

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.

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jennifer

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…”

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Karen Young

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.

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L

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.

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Karen Young

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.

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Vanessa

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

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Jane

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.

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Karen Young

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.

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Sally

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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Behaviour is never from ‘bad’. It’s from ‘big’. Big hungry, big tired, big disconnection, big missing, big ‘too much right now’. The reason our responses might not work can often be because we’ve misread the story, or we’ve missed an important piece of it. Their story might be about now, today, yesterday, or any of the yesterdays before now. 

Our job isn’t to fix them. They aren’t broken. Our job is to understand them. Only then can we steer our response in the right direction. Otherwise we’re throwing darts at the wrong target - behaviour, instead of the need behind the behaviour. 

Watch, listen, breathe and be with. Feel what they feel. This will help them feel you with them. We all feel safer and calmer when we feel our people beside us - not judging or hurrying or questioning. What don’t you know, that they need you to know?♥️
We all have first up needs. The difference between adults and children is that we can delay the meeting of these needs for a bit longer than children - but we still need them met. 

The first most important question the brain needs answered is, ‘Is my body safe?’ - Am I free from threat, hunger, exhaustion, pain? This is usually an easier one to take care of or to recognise when it might need some attention. 

The next most important question is, ‘Is my heart safe?’ - Am I loved, noticed, valued, claimed, wanted, welcome? This can be an easy one to overlook, especially in the chaos of the morning. Of course we love them and want them - and sometimes we’ll get distracted, annoyed, frustrated, irritated. None of this changes how much we love and want them - not even for a second. We can feel two things at once - madly in love with them and annoyed/ distracted/ frustrated. Sometimes though, this can leave their ‘Is my heart safe?’ needs a little hungry. They have less capacity than us to delay the meeting of these needs. When these needs are hungry, we’ll be more likely to see big feelings or big behaviour. 

The more you can fill their love tanks at the start of the day, the more they’ll be able to handle the bumps. This doesn’t have to be big. It just has to be enough. It might look like having a cuddle, reading a story, having a chat, sitting with them while they have breakfast or while they pat the dog, touching their back when they walk past, telling them you love them.

All brains need to feel loved and wanted, and as though they aren’t a nuisance, but sometimes they’ll need to feel it more. The more their felt sense of relational safety is met, the more they’ll be able to then focus on ‘thinking brain’ things, such as planning, making good decisions, co-operating, behaving. 

(And if this today was a bumpy one, that’s okay. Those days are going to happen. If most of the time their love tanks are full, they’ll handle when it drops a little. Just top it up when you can. And don’t forget to top yours up too. Be kind to yourself. You deserve it as much as they do.)♥️
Things will always go wrong - a bad decision, a good decision with a bad outcome, a dilemma, wanting something that comes with risk. 

Often, the ‘right thing’ lives somewhere in the very blurry bounds of the grey. Sometimes it will be about what’s right for them. Sometimes what’s right for others. Sometimes it will be about taking a risk, and sometimes the ‘right’ thing just feels wrong right now, or wrong for them. Even as adults, we will often get things wrong. This isn’t because we’re bad, or because we don’t know the right thing from the wrong thing, but because few things are black and white. 

The problem with punishment and harsh consequences is that we remove ourselves as an option for them to turn to next time things end messy, or as a guide before the mess happens. 

Feeling safe in our important relationships is a primary need for all of us humans. That means making sure our relationships are free from judgement, humiliation, shame, separation. If our response to their ‘wrong things’ is to bring all of these things to the table we share with them with them, of course they’ll do anything to avoid it. This isn’t about lying or secrecy. It’s about maintaining relational ‘safety’, or closeness.

Kids want to do the right thing. They want us to love and accept them. But they’re going to get things wrong sometimes. When they do, our response will teach them either that we are safe for them to come to no matter what, or that we aren’t. 

So what do we do when things go wrong? Embrace them, reject the behaviour:

‘I love that you’ve been honest with me. That means everything to me. I know you didn’t expect things to end up like this, but here we are. Let’s talk about what’s happened and what can be different next time.’

Or, ‘Something must have made this (wrong thing) feel like the right thing to do, otherwise you wouldn’t have done it. We all do that sometimes. What do you think it was that was for you?’

Or, ‘I know you know lying isn’t okay. What made you feel like you couldn’t tell me the truth? How can we build the trust again. Let’s talk about how to do that.’

You will always be their greatest guide, but you can only be that if they let you.♥️
Whenever there is a call to courage, there will be anxiety - every time. That’s what makes it brave. This is why challenging things, brave things, important things will often drive anxiety. 

At these times - when they are safe, but doing something hard - the feelings that come with anxiety will be enough to drive avoidance. When it is avoidance of a threat, that’s important. That’s anxiety doing it’s job. But when the avoidance is in response to things that are important, brave, meaningful, that avoidance only serves to confirm the deficiency story. This is when we want to support them to take tiny steps towards that brave thing. It doesn’t have to happen all at once.l and it doesn’t matter how long it takes. Brave is about being able to handle the discomfort of anxiety enough to do the important, challenging thing. It’s built in tiny steps, one after the other. 

We don’t have to get rid of their anxiety and neither do they. They can feel anxious, and do brave. At these times (safe, but scary) they need us to take a posture of validation and confidence. ‘I believe you, and I believe in you.’ ‘I know this feels big, and I know you can handle it.’ 

What we’re saying is we know they can handle the discomfort of anxiety. They don’t have to handle it well, and they don’t have to handle it for too long. Handling it is handling it, and that’s the substance of ‘brave’. 

Being brave isn’t about doing the brave thing, but about being able to handle the discomfort of the anxiety that comes with that. And if they’ve done that today, at all, or for a moment longer than yesterday, then they’ve been brave today. It doesn’t matter how messy it was or how small it was. Let them see their brave through your eyes.‘That was big for you wasn’t it. And you did it. You felt anxious, and you stayed with it. That’s what being brave is all about.’♥️
A relationally unsafe (emotionally unsafe) environment can cause as much breakage as as a physically unsafe one. 

The brain’s priority will always be safety, so if a person or environment doesn’t feel emotionally safe, we might see big behaviour, avoidance, or reduced learning. In this case, it isn’t the child that’s broken. It’s the environment.

But here’s the thing, just because a child doesn’t feel safe, doesn’t mean the person or environment isn’t safe. What it means is that there aren’t enough signals of safety - yet, and there’s a little more work to do to build this. ‘Safety’ isn’t about what is actually safe or not, it’s about what the brain perceives. Children might have the safest, warmest, most loving adult in front of them, but that doesn’t mean they’ll feel safe. This is when we have to look at how we might extend bigger cues of warmth, welcome, inclusiveness, and what we can do (or what roles or responsibilities can we give them) to help them feel valued and needed. This might take time, and that’s okay. Children aren’t meant to feel safe with every adult in front of them, so sometimes what they need most is our patience and understanding as we continue to build this. 

This is the way it works for all of us, everywhere. None of us will be able to give our best or do our best if we don’t feel welcome, liked, valued, and free from hostility, humiliation or judgement. 

This is especially important for our schools. A brain that doesn’t feel safe can’t learn. For schools to be places of learning, they first have to be places of relationship. Before we focus too sharply on learning support and behaviour management, we first have to focus on felt sense of safety support. The most powerful way to do this is through relationship. Teachers who do this are magic-makers. They show a phenomenal capacity to expand a child’s capacity to learn, calm big behaviour, and open up a child’s world. But relationships take time, and felt safety takes time. The time it takes for this to happen is all part of the process. It’s not a waste of time, it’s the most important use of it.♥️

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