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Breaking the eat, purge and repeat cycle of bulimia

Breaking the eat, purge and repeat cycle of bulimia

Early intervention, diagnosis and treatment could prevent this eating disorder from taking a serious turn, say doctors
Photo by Anantha Subramanyam K

What began as diarrhoea and dehydration for 21-year-old Jessica (name changed on request) from Chennai was eventually diagnosed to be bulimia nervosa, a serious eating disorder characterised by bouts of uncontrolled eating, which is followed by methods of purging.

When Jessica’s parents learnt about her condition, they were left shaken. The visibly worried parents found it hard to wrap their heads around the fact that their daughter had got used to a cycle of overeating, getting overtly conscious of her weight and then self-medicating purgatives to flush out the food intake in a fit of guilt. When Jessica was taken to a doctor, her parents found out that she had resorted to taking laxatives, a medication taken to treat constipation. In Jessica’s case, however, it led to loosen stools and increase her bowel movements, causing acute dehydration.

Back in the 1990s, Diana, Princess of Wales, had spoken about her struggle with bulimia in a public speech and encouraged people with eating disorders to talk about them. In a BBC interview, Diana said she had had bulimia for a number of years and called it a ‘secret disease’.

Body image issues

Commenting on Jessica’s condition, Dr V Mithun Prasad, Psychiatrist, SIMS Hospital, Chennai, says, “Eat, purge and repeat had become Jessica’s routine, which gradually affected her weight and her perception of body image.”

 “People with bulimia eat a large amount of food in a short span of time without check. They then resort to various unhealthy ways to get rid of the consumed food, including self-induced vomiting and usage of laxatives to eliminate the food from their bodies,” explains Dr Prasad.

Elaborating more on Jessica’s case, Dr Prasad told Happiest Health that while Jessica was healthy and had good fat in her body mass index (BMI), she seemingly misinterpreted her body image and craved to fit into a misplaced notion of an ideal body type. “Jessica grew way too conscious about her body appearance and resorted to getting slimmer in an unhealthy way. She had no control over eating and ate large portions at a time. She would then feel guilty about eating too much and gaining weight, and this soon turned into a loop,” Dr Prasad said.

Initially, Jessica’s parents were not aware of how their daughter felt and assumed that she was frequently falling ill. The doctors who treated her at the emergency room diagnosed her to have bulimia after learning her case history of repeatedly falling sick with diarrhoea and dehydration. They then referred her to a psychiatry department for further help and treatment.

Ways of purging

Dr Gautami Nagabhirava, Senior Psychiatrist, Kamineni Hospitals, Hyderabad, said that people with bulimia engage in unhealthy behaviours to avoid weight gain (purging). “Some of the common inappropriate compensatory behaviours associated with bulimia are excessive exercise, self-induced vomiting, misusing laxatives, diuretics (medicines to increase urine), enemas (fluids used to empty bowel) and weight loss pills,” she revealed.

According to Jessica’s doctor, in her case, the go-to item of misuse was laxatives, and each time she ate a lot, she would misuse aperients to purge herself of the excess intake. “Jessica’s parents found several laxatives at home, which they were not aware of earlier. She had low self-esteem, and it took several counselling sessions for us to bring back her confidence,” said Dr Prasad.

Symptoms to watch out for

Dr Nagabhirava said that people with bulimia generally experience the below signs and symptoms:

  • Dizziness
  • Palpitations
  • Gastrointestinal symptoms such as abdominal pain
  • Difficulty in swallowing
  • Bloating
  • Flatulence
  • Constipation
  • Menstrual irregularities
  • Scanty or absence of periods
  • Dehydration
  • Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium and other minerals), which can lead to stroke or heart attack

Dr Nagabhirava adds that signs like tooth decay and gum disease may be present due to repetitive vomiting. “Anxiety, depression, personality disorders and self-esteem issues are also prevalent among people with bulimia,” she said.

Some of the common visible signs are dental erosions, marks on upper palate and sores on fingernails and knuckles caused due to self-induced vomiting, says Dr Prasad, adding that family and friends can look out for signs like unexplained diarrhoea, dehydration and frequent vomiting episodes, which are repetitive for over three months, among patients.

How serious is bulimia nervosa?

A study on self-harm attempts in women with bulimia nervosa states that such incidents were frequent, often serious, and multiple. Interventions targeting depressive and impulsive features associated with bulimia are essential to reduce the risk of self-harm attempt in women with this disorder. Doctors insist that family members of people with typical symptoms of bulimia keep an eye on them and ensure they receive early intervention and diagnosis to prevent any mishap.

“Bulimia is a serious eating disorder, which could potentially be life-threatening if not treated on time,” says Dr Prasad corroborating the findings of the study.

What separates bulimia from anorexia and other conditions?

Dr Nagabhirava said that the main difference between anorexia and bulimia nervosa is that people with anorexia starve themselves, have a high self-control and are highly underweight with a low BMI. “Meanwhile people with bulimia are impulsive, emotionally labile and are normal weight or overweight, with no control over food,” she said.

 Not all who purge are bulimic

Giving another example of a 28-year-old man from Tamil Nadu, India, Dr Prasad said that in this case, the man would eat a lot and find ways to purge as he did not want to gain weight ahead of his brother’s wedding. “This was for a very short period, and he stopped to purge right after the wedding. He did not repeat it later and was not concerned about gaining weight. The purging was centric to an occasion and did not happen due to psychological issues related to his body image,” he said.

Stressing on the fact that this was not a case of bulimia, the doctor added that this makes it imperative for clinicians to carefully diagnose and treat the condition.

“People who eat and purge at least once a week for at least three months can be categorised as bulimics, while those who do it once in a while cannot be considered as suffering from bulimia,” said the doctor underscoring the difference.

What causes bulimia nervosa?

In a candid interview with BBC in 1995, Princess Diana of Wales, had spoken about her battle with bulimia and encouraged people with eating disorders to talk about their own struggles. “I had bulimia for a number of years,” Diana had said, calling it a “secret disease”.

The causes of bulimia are multifactorial, which include genetic susceptibility, family stress, personality disorders and a cultural obsession with a faulty notion of body image, explains Dr Nagabhirava.

She says that high index of suspicion is required as bulimics are not forthcoming since they are right or slightly overweight. “Certain red flags include an individual preoccupied with body image or being fat, repeatedly eating large quantities in one sitting, exercising too much and going to the washroom right after eating,” she said.

Diagnosis and treatment of Bulimia nervosa

Dr Prasad said that majority of the bulimia cases are clinically diagnosed and then referred to psychiatrist as people with the disorder are unlikely to disclose their condition. “Often dentists who notice dental erosions and wounds on their patients’ upper palate, general physicians observing case history of repeated diarrhoea, vomiting and dehydration direct their patients to psychiatrists for treatment and therapy,” he said.

Treatment includes psychotherapy (counselling) and pharmacotherapy (treatment through drugs), says Dr Nagabhirava. “Psychotherapy such as cognitive behavioural therapy, family therapy or interpersonal therapy along with administering antidepressants are the most effective modes of treatment,” she says, cautioning that the doctors decide on the treatment based on the condition of the individual patient and none should resort to self-medication.

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