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What Is Bulimia, and Can It Lead to Drug Abuse?

woman with tape across her mouth that says no food

According to the American Psychiatric Association (APA), feeding and eating disorders are characterized by some type of repetitive disruption in feeding or the eating process that consists of alterations in one’s consumption of food and/or an attempt by someone to alter the digestive process of food they have eaten. The qualification for a formal diagnosis of a mental health disorder related to this behavior can only be made if the behavior is frequent and repetitive, and the individual’s health or functioning in significant areas of their life is affected by these actions.

In addition, any mental health disorder can only be formally diagnosed by a licensed mental health clinician. Individuals who are concerned that their behavior or the behavior of a loved one may be the expression of a formal mental health disorder should consult with a professional.

There are several types of feeding and eating disorders that are recognized. The two major feeding and eating disorders are anorexia and bulimia. Many untrained individuals often confuse the two disorders; however, they are separate disorders that present with significant differences.

What Is Bulimia?

According to APA, bulimia, formally classified as bulimia nervosa, is an eating disorder that occurs when an individual repetitively engages in a series of cyclical binge eating episodes followed by some form of compensatory behavior that is designed to eliminate the food that was ingested during these binging periods. These types of compensatory behaviors may be quite varied. The behavior the individual engages in is also associated with potential dysfunctional or impairment in physical or emotional health, or in important areas of life, such as work, personal relationships, school, etc.

For an individual to be diagnosed with bulimia, they must engage in both the repetitive bingeing behaviors and the repetitive compensatory behaviors designed to eliminate food. Individuals who simply engage in numerous episodes of binge eating may be diagnosed with a binge eating disorder. Clinical expertise is often needed to ascertain whether an individual’s behavior is disordered and if it qualifies as a binge eating disorder, bulimia, or anorexia.

Formal diagnostic criteria are listed in the APA’s Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition as well as in a number of accompanying professional supplementary texts, such as Kaplan and Sadock’s Synopsis of Psychiatry.

  • The person must engage in repetitive binge eating episodes consisting of either:
    1. The consumption of extremely large amounts of food in a specific time, such that the food ingested is significantly larger than most people would eat in a similar time period under the same conditions
    2. The feeling that the person lacks control over their eating during these bingeing episodes and they are unable to stop eating
  • In addition, the diagnosis of bulimia requires that the individual also engages in repetitive compensatory behaviors aimed at reducing any potential weight gain associated with their binge eating episodes. These can be:
    1. Self-induced throwing up
    2. Repetitive use of laxatives following bingeing episodes
    3. Excessive use of exercise
    4. Severe fasting episodes
  • The individual attributes a great proportion of their notion of self-worth to the size of their body, such that they tend to base judgments on their weight as opposed to other variables.
  • Formal diagnostic criteria for bulimia indicate that these bingeing and compensatory behaviors need to occur at least an average of once a week over a minimum period of three months before a formal diagnosis can be made.
  • Bulimia cannot be diagnosed in individuals who have anorexia. These two disorders are considered mutually exclusive.

It should be noted that individuals who are diagnosed with anorexia may also demonstrate the binge/purge cycle. However, individuals with anorexia display significant and unhealthy weight loss and a distorted body image that borders on being delusional in nature (always viewing themselves as being too fat even if they are dangerously thin), whereas individuals diagnosed with bulimia typically do not display unhealthy weight loss and this distorted body image.

In its current diagnostic scheme, APA has characterized bulimia as occurring on a continuum of severity according to the number of compensatory behaviors (purging strategies) used by the individual in an average week. The particular type of compensatory strategy is not given any specific diagnostic weight; instead, the number of compensatory strategies that an individual engages in is used to determine the severity of disorder.

  • Individuals engaging in an average of 1-3 compensatory behaviors weekly would be diagnosed with mild bulimia nervosa.
  • An average of 4-7 compensatory strategies per week would qualify for moderate bulimia nervosa.
  • An average of 8-13 compensatory strategies weekly would qualify for a diagnosis of severe bulimia nervosa.
  • Engaging in 14 or more compensatory behaviors per week on average would result in a diagnosis of extreme bulimia nervosa.

These designations help clinicians to design appropriate interventions associated with an individual’s disorder. However, any expression of bulimia is a representation of a severe mental health disorder that requires formal intervention.

According to the book Eating Disorders: A Guide to Medical Care and Complications, some other signs that someone may be suffering from an eating disorder like bulimia include:

  • Noticing that relatively large amounts of food regularly disappear or finding empty food containers in an individual’s room that suggests that the person is eating large amounts on regular occasions
  • Frequent trips to the bathroom during or after meals or potential hiding of purging behaviors associated with bathroom visits, such as the person running the faucet while in the bathroom, the use of breath mints or frequently brushing their teeth, etc.
  • Swelling in the person’s cheeks or jaw and/or discolored or stained teeth
  • Obsessive involvement in exercise, such that the person exercises in situations that could obviously be harmful or dangerous, such as exercising when extremely sick, injured, in extremely increment weather, for extremely long periods of time, etc.
  • Calluses on the back of the hands or knuckles as an indicator of self-induced vomiting
  • Extreme attitudes regarding weight loss, food control, dieting, etc., such that they are the primary concern of the person
  • Finding signs of potential purging, such as evidence of laxative use, vomiting, guides to purging, etc.
  • Significant withdrawal from social activities in association with any of the above

These signs should not be used to definitively decide that an individual has developed some type of feeding/eating disorder, but they may be indicators that further investigation is warranted. For example, many dedicated individuals engage in exercise in situations that others may see as extreme. It is important to understand that these behaviors need to be repetitive and significantly extreme in their presentation. When in doubt, consult with a licensed mental health clinician.


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Who Suffers from Bulimia?

very thin, young woman suffering from bulimia is sitting in fetal position on the floor

APA and the National Institute of Mental Health report that bulimia is far more common in females than males; it is diagnosed at a ratio of 10 females to every male. The overall prevalence of bulimia is 1-1.5 percent of the US female population and about 0.06 percent of the entire population. Bulimia is more commonly diagnosed in adolescent females, and first-time diagnosis of bulimia in females older than 40 years old is rare. Many people occasionally engage in bingeing and purging episodes; when this behavior is occasional, it is not considered to be severe enough to qualify for a formal diagnosis.

The process of bingeing on food occurs often in individuals who have been trying to diet or lose weight. It is also a result of attempts to deal with stress in some individuals. When these individuals begin to frequently engage in bingeing episodes that are followed by compensatory purging episodes, they are at risk for developing the formal diagnosis of bulimia nervosa.

As might be expected, individuals with bulimia are at risk for a number of potential complications with their physical health. According to the book Bio-Psycho-Social Contributions to Understanding Eating Disorders, significant health concerns that can occur in individuals with bulimia include:

  • Problems with the esophagus as a result of frequent vomiting
  • Significant tooth decay due to repetitive vomiting and stomach acids being released into the mouth
  • Gastrointestinal disorders associated with vomiting, fasting, or the abuse of laxatives
  • Electrolyte imbalances associated with repetitive bingeing and purging
  • Significant cardiovascular damage due to electrolyte imbalances and other chemical imbalances in the body as a result of purging

Associated health issues that occur in individuals with bulimia can be very serious and, in some cases, can result in fatalities. APA also reports that individuals with bulimia are very likely to have some other co-occurring (comorbid) mental health disorder that further complicates their presentation and treatment. Most often, the co-occurring diagnoses include:

 Substance use disorders that are most commonly diagnosed as co-occurring disorders in individuals with bulimia include alcohol use disorders and stimulant use disorders. Stimulant abuse that co-occurs with a diagnosis of bulimia is most often a compensatory form of purging in an attempt for the individual to lose weight. Alcohol abuse in individuals with bulimia is believed to be a result of the individual attempting to deal with stress related to functional impairment associated with their eating disorder. When individuals use drugs or alcohol to deal with the stress related to the effects of some other mental health disorder, it is labeled as avoidance-based coping, and the effects of this activity often result in a downward spiral, such that substance abuse becomes distressing and disabling in itself, and greater substance abuse then occurs to compensate for the additional stress/dysfunction.

It should be noted that a number of research studies suggest that the high rate of co-occurring substance abuse that occurs in people with bulimia compared to other eating disorders may result from a number of different causal pathways. For example, individuals diagnosed with bulimia are far more than twice as likely as individuals diagnosed with anorexia to abuse alcohol, and they are far more likely to be diagnosed with polysubstance abuse. Researchers suggest that individuals with bulimia may have significant inherent vulnerability, such as genetic vulnerabilities or alterations in their central nervous system (the brain and spinal cord) that make them more vulnerable to addictive-type behaviors. This research also suggests that 30 percent or more of individuals diagnosed with bulimia have some form of substance abuse issue.


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Interventions for Bulimia

group intervention for bulimia

Individuals with bulimia are notoriously difficult to treat due to a number of co-occurring issues and because they often are not honest regarding their behavior. These individuals often do not see their behavior as dysfunctional even if their behavior results in significant impairment or dysfunction in relationships, work, recreational activities, health, etc. This is compounded by the potential for these individuals to also have co-occurring substance use disorders because they display the same types of avoidance and reactive behavioral tendencies.

The best approach is to find a licensed mental health professional who specializes in the treatment of these disorders. There are no formal medications that can treat eating disorders like bulimia without the use of psychotherapy. The best approach is a combination of medications, such as selective serotonin reuptake inhibitors (a type of antidepressant medication), other medications that are relevant in the particular situation, and very intense and involved psychotherapy. Psychotherapy for eating disorders often includes participation in both individual and group therapy sessions.

People who have co-occurring substance use disorders can also benefit from participation in 12-Step groups, such as Alcoholics Anonymous. Anyone with bulimia can benefit from social support groups for eating disorders.