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Bulimia Definition Symptoms Causes and Treatment?

Definition of Bulimia

Bulimia is part of eating disorders or eating disorders, as is anorexia nervosa and hyperphagia.

Bulimia is characterized by the occurrence of bouts of bulimia or overeating crises during which the person ingests huge amounts of food without being able to stop. Some studies suggest an absorption ranging from 2000 to 3000 kcal per crisis. Bulimic people feel totally out of control during crises and feel ashamed and guilty after these. After the onset of a seizure, people engage in inappropriate compensatory behaviors to try to eliminate the intake of calories and avoid weight gain.. Bulimic people often resort to vomiting , misuse of drugs (laxatives, purgatives, enemas, and diuretics), intensive exercise or fasting.

Unlike anorexic persons underweight, the bulimic person has a usually normal weight.

In summary, bulimia is a disease that is characterized by the occurrence of seizures during which the person feels to lose control over his behavior that leads him to quickly absorb a huge amount of food . This is followed by the introduction of inappropriate compensatory behaviors to prevent weight gain.

Bulimia binge

The binge eating disorder is another eating disorder. He is very close to bulimia. We observe the presence of overeating crises but there is no compensatory behavior to avoid weight gain. People with binge eating disorders are often overweight.

Anorexia with binge eating

Some people have both the symptoms of anorexia nervosa and bulimia nervosa. In this case, we are not talking about bulimia but about anorexia with bouts of bulimia .


Bulimia as a behavior has been known since ancient times. Literature tells us about the Greek and Roman orgies, “meetings” during which the guests indulged in all sorts of excesses, including excess of food, even to the point of becoming sick and vomiting.

Bulimia as a disorder is described since the 1970s According to studies and diagnostic criteria (broad or restrictive) used, there is a prevalence of 1% to 5.4% of girls interested in Western societies. This prevalence makes it an even more widespread disease than anorexia nervosa, especially as the number of people affected continues to increase. Finally, it would affect 1 man for 19 women concerned.

Diagnostic of bulimia

Although the signs of bulimia often appear towards the end of adolescence, the diagnosis is only made on average 6 years later. Indeed, this eating disorder strongly associated with shame does not easily lead the bulimic person to consult. The earlier the pathology is identified, the earlier the therapeutic intervention can begin and the chances of recovery are increased.

The causes of bulimia?

Bulimia has been a  eating behavior disorder that has  been in evidence since the 1970s. Numerous studies have been conducted on bulimia since then, but the exact causes of the appearance of this disorder are still unknown. However, hypotheses, still under study, try to explain the occurrence of bulimia.

Researchers agree that many factors are at the origin of bulimia including  genetic factors ,  neuroendocrine ,  psychological ,  family  and  social .

Although no gene has been clearly identified , studies highlight a family risk. If in a family, a member is suffering from bulimia, there is more chance that another person in this family will be affected by this disorder than in a “healthy” family. Another study conducted on identical twins (monozygotes) shows that if one of the twins is affected by bulimia, there is a 23% chance that her twin is also affected. This probability increases to 9% in the case of different twins (dizygotes). It would seem that genetic elements play a role in the development of bulimia.

Of  endocrine factors  such as hormonal deficit appear to be involved in this disease. The reduction of a hormone (LH-RH) involved in the regulation of ovarian function is highlighted. However, this deficit is observed when there is a weight loss and the observations find a normal level of LH-RH with the recovery of weight. This disorder seems to be a consequence of bulimia rather than a cause.

At  the neurological level , many studies link a serotonergic dysfunction with a satiety sensation often observed in bulimics. Serotonin is a substance that ensures the passage of the nerve message between neurons (synapses). She is particularly involved in stimulating the center of satiety (area of ​​the brain that regulates appetite). For many reasons still unknown, there is a decrease in the amount of serotonin in people with bulimia and a tendency to increase this neurotransmitter after healing.

On the  psychological level , many studies have made the link between the onset of bulimia with the presence of a  low self-esteem  based largely on body image. Hypotheses and analytic studies find some constants in the personality and feelings experienced by bulimic adolescent girls. Bulimia often affects young people who have difficulty expressing their feelings and who often find it difficult to identify their own  bodily  sensations (feelings of hunger and satiety). Psychoanalytic writings often evoke a  rejection of the body as a sexual object. These teenagers would unconsciously wish to remain little girls. The disorders caused by the disorders of the alimentary behaviors put at risk the body which “regresses” ( absence of menstruation s, loss of the forms with the decrease of weight, etc …). Finally, studies on the personality of people affected by bulimia, find some common personality traits such as:  conformism ,  lack of initiative ,  lack of spontaneity ,  inhibition of behavior  and  emotions , etc …

At  the cognitive level , the studies put forward  negative automatic thoughts  leading to false beliefs often present in bulimics such as “thinness is a guarantee of happiness” or “any fat intake is bad”.

Finally, bulimia is a pathology that affects more the population of the industrialized countries. The  sociocultural factors  therefore play an important role in the development of bulimia. The images of “the perfect woman” who works, raises her children and controls her weight are widely conveyed by the media. These representations can be taken with distance by adults well in their skin but they can have devastating effects on teenagers lacking landmarks.

Associated disorders

We find mainly  psychopathological disorders  associated with bulimia. However, it is difficult to know if it is the appearance of bulimia that will cause these disorders or if the presence of these disorders will lead the person to become bulimic.

The main psychological disorders associated, are:

  • depression, 50% of people with bulimia would develop a major depressive episode during their lifetime;
  • anxiety disorders, which would be present in 34% of bulimics;
  • the  risk behaviors such as substance abuse (alcohol, drugs) that would affect 41% of bulimics;
  • a  low self-esteem  making, bulimic people more sensitive to criticism and especially self-esteem excessively linked to body image;
  •  personality disorder , which affects 30% of people with bulimia.

Extreme periods of fasting and compensatory behaviors (purges, use of laxatives, etc.) lead to complications that can cause serious kidney, heart, gastrointestinal and dental problems.

People at risk and risk factors

Bulimia would begin in the  late teens . It would affect  girls more  than boys (1 boy with 19 girls). Bulimia and other eating disorders affect the populations of  industrialized countries more . Finally, some professions (athlete, actor, model, and dancer) for whom it is important to have some  control of their weight  and  body image , would have more people suffering from eating disorders than other trades .

Bulimia nervosa would start 5 times out of 10 during  dieting . For 3 out of 10 people, bulimia was preceded by anorexia nervosa. Finally, 2 times out of 10, it is a depression that ushered in the onset of bulimia.


Can we prevent?
Although there is no safe way to prevent the onset of this disorder, there may be ways to detect it early and contain its evolution.

For example, the pediatrician and / or general practitioner may be important in identifying early indicators that may suggest an eating disorder. During a medical visit, do not hesitate to tell him about your concerns about the eating behavior of your child or teenager. Thus warned, he will be able to ask him questions about his eating habits and the satisfaction or not that he feels about his bodily appearance. In addition, parents can cultivate and reinforce a healthy body image of their children, regardless of their size, shape and appearance. It is important to be careful to avoid any negative jokes about it.


This eating disorder is linked to a real  compulsive crisis  as well as a  loss of control of the mind on the body , so  daily activities  such as eating meals in society can be a real challenge for people with bulimia. .

  • Phases  overeating  during which the person will eat until reaching the point of discomfort or pain. Food intake will be much higher than that taken during a normal meal or snack;
  • Fasting phases thinking that they can restore weight gain;
  • Vomiting  provoked after eating;
  • Taking  diuretics ,  laxatives  or  enemas  ;
  • Intensive sports practice  ;
  • isolation  ;
  • Mood swings,  irritability , sadness, guilt,  shame  ;
  • Abnormal concerns about body shape and weight leading to negative distorted vision of the body image.


Conduct of a bulimia crisis

The pre-crisis

The  perfectionism  that guides the bulimic person creates inner tensions as well as feelings of lack, anxiety and irritability.


A  loss of control  and the  need to satisfy an impulse  can then invade the bulimic person. The beginning of the crisis corresponds to the moment when the will gives in to this impulse which becomes unbearable and where the bulimic person will try to compensate what is most often felt like an interior emptiness.

To do so, she will  ingest a large amount of food in a very short time , to the detriment of the notion of pleasure. The foods are chosen and are preferably  sweet and high in calories .

A feeling of guilt will surpass the satisfaction of seeing the impulse satisfied and will lead to the vomiting phase. This is a  real purge , supposed to bring some  relief . In some cases,  vomiting  may also be accompanied by laxatives, diuretics or even enemas.

The post-crisis

Shame and guilt  then give way to a feeling of  disgust , which will result in a desire to regain control of oneself and not to start again. But these crises are part of a  vicious circle  that is difficult to get out of thanks to the will, because, more than just a habit, bulimia attacks are part of a  ritual .

Psychopathological evaluation

To establish a diagnosis of bulimia , various factors must be observed in the behavior of the person.

In North America, the standard screening tool is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In Europe and elsewhere in the world, health professionals generally use the International Classification of Diseases (ICD-10).

In summary, in order to evoke a bulimic disorder, we must note the presence of bouts of bulimia during which the person has the impression that she totally loses control of her behavior which will lead her to consume in a limited period of time a quantity food far superior to normal. Finally, the presence of compensatory behaviors is necessary to talk about bulimia knowing that crises and compensatory behaviors must occur on average twice a week for 3 consecutive months. Finally, the doctor will assess the self-esteem of the person to see if it is excessively influenced by weight and silhouette as is the case in bulimic people.

Somatic evaluation

In addition to psychopathological assessment , a complete physical examination is often required to evaluate the consequences of purging and other compensatory behaviors on the patient ‘s health.

The exam will look for problems:

  • heart diseases such as heart rhythm disorders;
  • dental, including erosion of tooth enamel;
  • gastrointestinal disorders such as bowel movement disorders;
  • bone , including a decrease in bone mineral density;
  • renal  ;
  • Dermatological .

EAT-26 Screening Test

The EAT-26 test can detect people who may be suffering from eating disorders. It is a questionnaire of 26 items that the patient informs alone and then gives to a professional who analyzes it. The questions will help to question the presence and the frequency of the diets, the compensatory behaviors and the control that the person exerts on his feeding behavior.

Source: for the French version of the EAT-26 screening test, Leichner et al. 1994 9

Complications of bulimia

The main complications of bulimia are the more or less serious physiological disorders induced by compensatory purging behaviors.

The vomiting repeatedly can cause various ailments such as erosion of tooth enamel, inflammation of the esophagus, salivary gland swelling and decreased potassium levels can cause rhythm disorders or heart failure .

The laxative causes too many problems including intestinal sluggishness can be observed (lack of tone of the digestive tract) causing constipation, dehydration, edema and even lower levels of sodium can lead to kidney failure.

Regarding dietary restrictions , these can induce anemia, amenorrhea (stop menstruation), hypotension, cardiac slowdown and a drop in calcium that can cause osteoporosis.

Finally, substance abuse (drugs and alcohol), often present in people with bulimia, can lead to other somatic disorders. In addition, the use of these substances can also lead the person to adopt risky behaviors because of disinhibition (unprotected sex, etc …).

It is difficult to get out of bulimia without accompaniment . The prescription of drugs and the proposal to undertake psychotherapy can then be considered to cure bulimia. Sometimes specialized hospitalization may be necessary.

Medication management

Some medications may be prescribed to reduce the symptoms of bulimia (fewer attacks) but also to treat related disorders such as anxiety and depression. Finally, after a medical assessment of the physiological consequences of purging (digestive, renal, cardiac, endocrine, etc.) disorders, the doctor may prescribe examinations (blood tests) and medications to treat these disorders.

The antidepressants can help reduce the symptoms of bulimia. The Food and Drug Administration recommends the preferential prescription of fluoxetine (Prozac) in the context of bulimia. This antidepressant is part of the class of antidepressants that work by inhibiting serotonin reuptake (SSRI). This drug works by increasing the amount of neurotransmitter serotonin in synapses (junction between two neurons). The increased presence of serotonin facilitates the passage of nerve information.

However, depending on the disorders presented by his patient (other associated psychopathological disorders), the doctor may prescribe other antidepressants or drugs (including some anxiolytics) to treat bulimia.

Psychotherapeutic accompaniment

Psychotherapies are offered for the most part, individually or in groups , but all have the following objectives: to improve the perception and self-esteem of the bulimic person and to work on certain conflicts.

  • Cognitive behavioral therapies (CBT)

They are very effective in treating the symptoms of bulimia as it is to bring the patient to observe his pathological behavior (here, it will be crises but also purging behaviors) and then modify them. The goal of CBT is not to find the causes or the origin of the disorder but to act on it.

The psychotherapist intervenes in the mental processes (thought patterns) and emotions that regulate the patient’s behavior and motivates him to re-evaluate the choices that led him to give in to a crisis.

The patient is very active in CBT, he will have to fill many grids and questionnaires. In the context of bulimia, in general about twenty sessions are necessary to question and modify the dysfunctional thoughts of the patient related to diet , weight and body image , self – esteem , etc …

  • Family Systemic Therapy

This therapy is called ” systemic ” because it considers the family group as a system and a set of interrelated elements. In this case, the family is not made up of independent elements (parents / children), but entities that influence each other.

Family systemic therapy studies the modes of communication and the different interactions within the family in order to subsequently improve the internal relationships. When a member of a family is affected by an illness like bulimia, the other members will be affected. For example, meal times can be particularly complicated to manage for the family. The actions and words of one or the other can be helpful or, on the contrary, harmful for the patient. It is not a matter of blaming each other, or of making them guilty of bulimia, but of taking into consideration their suffering and advancing everyone in the right direction for them, but also for the sick person.

  • Psychodynamic psychotherapy

This psychotherapy is inspired by psychoanalysis . It is widely used to accompany the patient in the search for conflicts (personal, interpersonal, conscious and unconscious, etc …) that may be at the origin of the onset of eating disorders.

  • Interpersonal psychotherapy

This short therapy, especially used to treat depression, is proven to support people with eating disorders. During the interpersonal psychotherapy, the subject will not be the food but the actual interpersonal difficulties of the patient which necessarily have consequences on his feeding behavior.

  • Nutritional therapy

This psycho-educational therapy is very important and effective in addition to psychotherapy. Indeed, the benefits it can bring do not last if it is done alone, bulimia is often only a symptom that reflects a deeper evil.

It is used by people who also suffer from other eating disorders.

Nutritional therapy will allow the patient to relearn how to eat: eating a balanced diet , apprehending taboo foods (especially sugary, which led to vomiting), eating slow sugars again to avoid seizures, getting used to meals sitting at home. Table, 4 a day, in reasonable quantities. Information related to weight and diet will be provided and explained such as the theory of natural weight. With this therapy, we try to change the relationship that the patient has with the diet. Finally, this method is also interested in compensatory purging behaviors that used to be used by the patient. It also aims to allow him to lose the habit of using methods such as laxatives if this was the case by providing theoretical information that will explain the inefficiency of such behavior.

The Canadian Food Guide (GAC)
This guide is a very good tool to relearn how to eat well as it is often the case when one suffers from eating disorders. It divides food into 5 categories: grain products, vegetables and fruits, dairy products, meat and alternatives and other foods, i.e., pleasure foods that do not belong to other groups. This last category, which is rarely found in guides, is very interesting for people suffering from anorexia or bulimia because this category fills the psychological needs more than the nutritional needs of the person. Each meal should contain at least 4 out of 5 groups per month. Each group brings unique nutrients.


Sometimes specialized hospitalization may be necessary to increase the patient’s chances of recovery, after failure of outpatient treatment and when significant health problems are identified. Depending on the institution, specialized conventional hospitalization or day hospitalization may be offered. For the latter, the person will go to the hospital every day of the week to receive care and will return to his home in the evening.

In a service specializing in the management of eating disorders, the patient receives care from a multidisciplinary team (doctor, nutritionist, psychologist, etc …). The treatment often includes nutritional rehabilitation , psycho-educational support and follow-up in psychotherapy .

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