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.

Reply
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.

Reply
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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The temptation to fix their big feelings can be seismic. Often this is connected to needing to ease our own discomfort at their discomfort, which is so very normal.

Big feelings in them are meant to raise (sometimes big) feelings in us. This is all a healthy part of the attachment system. It happens to mobilise us to respond to their distress, or to protect them if their distress is in response to danger.

Emotion is energy in motion. We don’t want to bury it, stop it, smother it, and we don’t need to fix it. What we need to do is make a safe passage for it to move through them. 

Think of emotion like a river. Our job is to hold the ground strong and steady at the banks so the river can move safely, without bursting the banks.

However hard that river is racing, they need to know we can be with the river (the emotion), be with them, and handle it. This might feel or look like you aren’t doing anything, but actually it’s everything.

The safety that comes from you being the strong, steady presence that can lovingly contain their big feelings will let the emotional energy move through them and bring the brain back to calm.

Eventually, when they have lots of experience of us doing this with them, they will learn to do it for themselves, but that will take time and experience. The experience happens every time you hold them steady through their feelings. 

This doesn’t mean ignoring big behaviour. For them, this can feel too much like bursting through the banks, which won’t feel safe. Sometimes you might need to recall the boundary and let them know where the edges are, while at the same time letting them see that you can handle the big of the feeling. Its about loving and leading all at once. ‘It’s okay to be angry. It’s not okay to use those words at me.’

Ultimately, big feelings are a call for support. Sometimes support looks like breathing and being with. Sometimes it looks like showing them you can hold the boundary, even when they feel like they’re about to burst through it. And if they’re using spicy words to get us to back off, it might look like respecting their need for space but staying in reaching distance, ‘Ok, I’m right here whenever you need.’♥️
We all need certain things to feel safe enough to put ourselves into the world. Kids with anxiety have magic in them, every one of them, but until they have a felt sense of safety, it will often stay hidden.

‘Safety’ isn’t about what is actually safe or not, but about what they feel. At school, they might have the safest, most loving teacher in the safest, most loving school. This doesn’t mean they will feel enough relational safety straight away that will make it easier for them to do hard things. They can still do those hard things, but those things are going to feel bigger for a while. This is where they’ll need us and their other anchor adult to be patient, gentle, and persistent.

Children aren’t meant to feel safe with and take the lead from every adult. It’s not the adult’s role that makes the difference, but their relationship with the child.

Children are no different to us. Just because an adult tells them they’ll be okay, it doesn’t mean they’ll feel it or believe it. What they need is to be given time to actually experience the person as being safe, supportive and ready to catch them.

Relationship is key. The need for safety through relationship isn’t an ‘anxiety thing’. It’s a ‘human thing’. When we feel closer to the people around us, we can rise above the mountains in our way. When we feel someone really caring about us, we’re more likely to open up to their influence
and learn from them.

But we have to be patient. Even for teachers with big hearts and who undertand the importance of attachment relationships, it can take time.

Any adult at school can play an important part in helping a child feel safe – as long as that adult is loving, warm, and willing to do the work to connect with that child. It might be the librarian, the counsellor, the office person, a teacher aide. It doesn’t matter who, as long as it is someone who can be available for that child at dropoff or when feelings get big during the day and do little check-ins along the way.

A teacher, or any important adult can make a lasting difference by asking, ‘How do I build my relationship with this child so s/he trusts me when I say, ‘I’ve got you, and I know you can do this.’♥️
There is a beautiful ‘everythingness’ in all of us. The key to living well is being able to live flexibly and more deliberately between our edges.

So often though, the ‘shoulds’ and ‘should nots’ we inhale in childhood and as we grow, lead us to abandon some of those precious, needed parts of us. ‘Don’t be angry/ selfish/ shy/ rude. She’s not a maths person.’ ‘Don’t argue.’ Ugh.

Let’s make sure our children don’t cancel parts of themselves. They are everything, but not always all at once. They can be anxious and brave. Strong and soft. Angry and calm. Big and small. Generous and self-ish. Some things they will find hard, and they can do hard things. None of these are wrong ways to be. What trips us up is rigidity, and only ever responding from one side of who we can be.

We all have extremes or parts we favour. This is what makes up the beautiful, complex, individuality of us. We don’t need to change this, but the more we can open our children to the possibility in them, the more options they will have in responding to challenges, the everyday, people, and the world. 

We can do this by validating their ‘is’ without needing them to be different for a while in the moment, and also speaking to the other parts of them when we can. 

‘Yes maths is hard, and I know you can do hard things. How can I help?’

‘I can see how anxious you feel. That’s so okay. I also know you have brave in you.’

‘I love your ‘big’ and the way you make us laugh. You light up the room.’ And then at other times: ‘It can be hard being in a room with new people can’t it. It’s okay to be quiet. I could see you taking it all in.’

‘It’s okay to want space from people. Sometimes you just want your things and yourself for yourself, hey. I feel like that sometimes too. I love the way you know when you need this.’ And then at other times, ‘You looked like you loved being with your friends today. I loved watching you share.’

The are everything, but not all at once. Our job is to help them live flexibly and more deliberately between the full range of who they are and who they can be: anxious/brave; kind/self-ish; focussed inward/outward; angry/calm. This will take time, and there is no hurry.♥️
For our kids and teens, the new year will bring new adults into their orbit. With this, comes new opportunities to be brave and grow their courage - but it will also bring anxiety. For some kiddos, this anxiety will feel so big, but we can help them feel bigger.

The antidote to a felt sense of threat is a felt sense of safety. As long as they are actually safe, we can facilitate this by nurturing their relationship with the important adults who will be caring for them, whether that’s a co-parent, a stepparent, a teacher, a coach. 

There are a number of ways we can facilitate this:

- Use the name of their other adult (such as a teacher) regularly, and let it sound loving and playful on your voice.
- Let them see that you have an open, willing heart in relation to the other adult.
- Show them you trust the other adult to care for them (‘I know Mrs Smith is going to take such good care of you.’)
- Facilitate familiarity. As much as you can, hand your child to the same person when you drop them off.

It’s about helping expand their village of loving adults. The wider this village, the bigger their world in which they can feel brave enough. 

For centuries before us, it was the village that raised children. Parenting was never meant to be done by one or two adults on their own, yet our modern world means that this is how it is for so many of us. 

We can bring the village back though - and we must - by helping our kiddos feel safe, known, and held by the adults around them. We need this for each other too.

The need for safety through relationship isn’t an ‘anxiety thing’. It’s a ‘human thing’. When we feel closer to the people around us, we can rise above the mountains that block our way.♥️

That power of felt safety matters for all relationships - parent and child; other adult and child; parent and other adult. It all matters. 

A teacher, or any important adult in the life of a child, can make a lasting difference by asking, ‘How do I build my relationship with this child (and their parent) so s/he trusts me when I say, ‘I’ve got you, I care about you, and I know you can do this.’♥️
Approval, independence, autonomy, are valid needs for all of us. When a need is hungry enough we will be driven to meet it however we can. For our children, this might look like turning away from us and towards others who might be more ready to meet the need, or just taking.

If they don’t feel they can rest in our love, leadership, approval, they will seek this more from peers. There is no problem with this, but we don’t want them solely reliant on peers for these. It can make them vulnerable to making bad decisions, so as not to lose the approval or ‘everythingness’ of those peers.

If we don’t give enough freedom, they might take that freedom through defiance, secrecy, the forbidden. If we control them, they might seek more to control others, or to let others make the decisions that should be theirs.

All kids will mess up, take risks, keep secrets, and do things that baffle us sometimes. What’s important is, ‘Do they turn to us when they need to, enough?’ The ‘turning to’ starts with trusting that we are interested in supporting all their needs, not just the ones that suit us. Of course this doesn’t mean we will meet every need. It means we’ve shown them that their needs are important to us too, even though sometimes ours will be bigger (such as our need to keep them safe).

They will learn safe and healthy ways to meet their needs, by first having them met by us. This doesn’t mean granting full independence, full freedom, and full approval. What it means is holding them safely while also letting them feel enough of our approval, our willingness to support their independence, freedom, autonomy, and be heard on things that matter to them.

There’s no clear line with this. Some days they’ll want independence. Some days they won’t. Some days they’ll seek our approval. Some days they won’t care for it at all, especially if it means compromising the approval of peers. The challenge for us is knowing when to hold them closer and when to give space, when to hold the boundary and when to release it a little, when to collide and when to step out of the way. If we watch and listen, they will show us. And just like them, we won’t need to get it right all the time.♥️

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