Bulimia: Risk Factors and Treatment

At the heart of the struggle with Bulimia Nervosa is an extreme focus and worry about weight and body shape, with a person’s sense of self and judgements of self-worth dependant on achieving a particular body shape and weight ideals. Thoughts often involve themes of low self-esteem; being dissatisfied with body image and need for perfection.

A person with bulimia can experience cognitive distortions very intensely and frequently:

• All or Nothing Thinking e.g. “I can eat the whole box of chocolates or none at all”
• Overgeneralisation e.g. “When I ate carbohydrates I was fat, so I can’t eat them at all”
• Magnification or minimisation e.g. “If others notice I’ve gained weight, I can’t go out”
• Disqualifying the positives: “When they say I look healthy, they really mean I’ve put on weight, I’m fat”

The Cycle of Bulimia

Behaviour becomes very reactive to thoughts about the body and aimed at avoiding any weight gain to an extreme degree. This often involves developing very rigid rules regarding diet and engaging in extreme dieting behaviour (Fairburn and Cooper, 2004). The rules are so rigid and difficult to follow that when they are naturally broken, the person can become very self-critical, let go of all control around eating and binge for a period. The binge eating involves eating in a discrete period of time an amount of food that is obviously larger than most would eat in similar contexts and period of time. In an attempt to compensate for the binge eating, the person gets caught up in compensatory behaviours such as vigorous exercising, induced vomiting or misuse of purgatives or diuretics.

The struggle continues with the fixation on body shape and weight, low self-esteem and extreme dieting behaviour. The compensatory behaviours of induced vomiting or misuse of purgatives or diuretics can maintain binge eating when the person believes these are an effective strategy for reducing the body’s absorption of the calories. The Bulimic may get caught up in a cycle of believing they can binge on ‘banned’ foods without this impacting their weight ideal. Further, the extreme weight loss dieting can have a physiological impact of inadequate nutrition and trigger a starvation reaction. This is experienced as an extreme urge to eat and seems uncontrollable leading to a binge and the cycle of compensatory behaviours to follow. The binge eating and compensatory behaviours are often associated with feelings of guilt, shame and disgust.

Prevalence of Bulimia 

It is estimated that 4% of the Australian population have an eating disorder and of these, 12% have bulimia nervosa (Butterfly Foundation, 2012). Unfortunately, it is common for people with bulimia to keep their disorder secret struggling with shame, guilt and disgust associated with the episodes of out of control eating and compensatory behaviours. It is estimated that the true prevalence of bulimia is 1 in 5 females (NEDC 2012). The prevalence of eating disorders is increasing among boys and men (NEDC 2012).

Risk factors for Bulimia 

The following outlines some of the factors that may increase a person’s likelihood of developing bulimia:

• low self-esteem
• overvaluing body image in evaluating self-worth
• perfectionistic traits
• symptoms of depression, anxiety, worrying or stress
• social avoidance and isolation
• placing high importance on others’ evaluations, comments or perceptions
• having experienced trauma
• struggle with challenging life events or family circumstances
• socio-cultural influences such as media messages about what constitutes beauty with an emphasis on thinness or muscularity and being involved in activities where body shape and weight are a significant focus (e.g. gym programs and sports such as gymnastics; dancing or athletics).

Possible Consequences of Bulimia on Health and Wellbeing 

Bulimia is a serious disorder. A person struggling with bulimia can suffer inflammation and rupture of the oesophagus and stomach as a result of frequent vomiting; chronic sore throat, reflux and indigestion; dental enamel erosion; stomach ulcers; problems with bowel movements as a result of misuse of laxatives (chronic constipation or diarrhoea); osteoporosis; irregular or loss of menstrual cycle; increased risk of fertility issues and slow or irregular heart beat which can increase the chance for heart failure (NEDC, 2019). There may also be a negative impact on social engagement, relationships and work. For these reasons it is important to seek help as soon as a problem is identified.

Psychological Treatment of Bulimia

Psychological treatment of Bulimia involves addressing both cognitive and behavioural aspects of the disorder and aims to restore appropriate eating behaviour (Fairburn and Cooper, 2004). It also involves addressing other issues in the person’s life depending on the individual treatment goals and presenting concerns such as problems in relationships, sense of purpose or meaning in life, employment/career and health issues.

The journey of treatment for Bulimia may involve the following and is individually tailored to the particular needs of the individual:

• Assessment to understand the person’s experience, struggles, particular beliefs regarding weight and body shape, eating patterns, behaviours used to control weight, other struggles in daily life and focus for treatment (symptoms of depression; anxiety; suicidal thoughts; relationship issues; sense of self; social life and home environment), report on any physical health issues, review of recent health checks and weight and weight history.
• Support and strategies for exploring a broader, more flexible sense of self, connecting with personal values about who and what is meaningful in life and the personal characteristics to develop to create a rich, full and meaningful life.

These inform broader therapy goals and provide motivation for behaviour change.

• The therapist supports exploring how the eating problem may have evolved (e.g. influences of cultural ideas of attractive body shape; family and peers; exposure of particular diets and gym programs and how self-worth became dependent on body ideals).
• Self-monitoring completing a written record of eating patterns along with the context for any problem eating such as emotions, thoughts and situations to help identify specific issues to be addressed in the therapy.
• Setting the goal to only weigh once per week. Weighing more frequently can trigger unnecessary concerns as the body naturally changes in weight with changes in fluid balance. Treatment addresses anxiety and thoughts regarding the weighing.
• Working through relevant education and evaluating beliefs and behaviour accordingly (e.g. on healthy body weight range; physical problems resulting from binge eating; that self-induced vomiting does not remove all the food eaten in a binge).
• Exploring the problems with extreme dieting.
• In the treatment of Bulimia, support can be provided to let go of extreme dieting and instead focus on a healthy eating plan to nurture the body and enhance self-care.
• It is recommended to have 3 to 4 planned meals each day and 1 or 2 planned snacks spaced at intervals of about 3 to 4 hours.
• Tips to support the eating plan include practising mindful eating and not watching TV or doing other activities whilst eating, having one place in the home to eat and set up for this purpose, only serving the appropriate portion size and be prepared for shopping adhering to the meal plan.
• Treatment of Bulimia can address strategies for riding the wave of urges to binge and encourage engaging in valued and pleasurable activities including those that improve self-worth.
• Strategies can also be utilised to unhook from unhelpful thoughts and have behaviour guided by personal values of health and self-care.
• Thoughts are problematic when being caught up in them, automatically believing them and they can influence behaviour. It is helpful to explore the costs and benefits of having particular thoughts influence behaviour and evaluate the thoughts against the education available and self-care values to support the goals of treatment.

If you think you may be struggling with bulimia seek help! This is a serious problem left untreated and you can recover with willingness to make changes for your longer-term health and wellbeing. Discussing your concerns with your GP and a psychologist are great options to begin. The involvement of other professionals may be relevant such as a dietician to guide an eating plan.

At CBT Professionals we have a number of clinical psychologists experienced in working with eating disorders. If you wish to consult with our service, please download our Referral Information sheet here and take this with you to your consultation with your GP.

CBT Professionals – Feel good, Live well 

Disclaimer: Content on this website is provided for education and information purposes only and is not intended to replace advise from your doctor or registered health professional. Readers are urged to consult their registered practitioner for diagnosis and treatment for their medical concerns. 

References:

Butterfly Foundation. (2012). Paying the Price: the economic and social impact of eating disorders in Australia. Melbourne, Butterfly Foundation.

Fairburn, C.G. and Cooper, P.J. (2004). Eating disorders. In Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide, (ed. K. Hawton, P. M. Salkovskis, J. Kirk, and D. M. Clark). Pp. 277–314). Oxford University Press, Oxford.

The National Eating Disorders Collaboration (2012). An integrated response to complexity – National eating disorders framework 2012. Sydney, NEDC.

NEDC. Bulimia nervosa. 2019. https://www.nedc.com.au. [accessed 28/2/2019].