How is bulimia diagnosed and treated?

How is bulimia diagnosed?

There are a number of healthcare providers that may help determine the diagnosis of bulimia, these include general practitioners, mental health professionals, social workers, psychiatric nurses, paediatricians, and other medical specialists. These professionals may work together as a medical team or individually with the patient.

If a doctor suspects that the person has bulimia, then he or she will usually perform:

• A complete physical examination
• Blood and urine tests - These are conducted to rule out any other conditions and confirm a diagnosis.
• A psychological evaluation - This is likely to be conducted by a mental health professional and will include the patient discussing their eating habits and their feelings and attitudes about food. This evaluation will also assess the patient for the presence of depression or other mental disorders such as anxiety, through exploring their history of mental health symptoms. This is done to determine the possible cause or risk factors for bulimia or other eating disorders.

The medical professional involved may also require additional tests and scans to be conducted in order to determine the exact diagnosis and rule out any medical conditions that may be contributing to weight changes or related complications.

Criteria for diagnosis of bulimia

In order for bulimia to be correctly diagnosed, the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM-5, offers criteria specifically for the diagnosis of the eating disorder. Some mental health care professionals may use this in addition to the aforementioned forms of diagnosis.

According to the criteria, a person must display the below points in order to be diagnosed with bulimia nervosa:

• The person must have recurrent episodes of binge eating. Binge eating episodes are characterised by both of the below actions:
  • Eating food in a discrete period of time, for example, eating within any two-hour period, a large amount of food that is considerably more than the average person would eat in the same time period.
  • Sensing a lack of control when eating during these binge episodes, for example, the individual may feel as though they are unable to stop eating or control what they are eating or how much food they are ingesting.
• The person experiences episodes of inappropriate and recurrent behaviour to compensate for the guilt associated with eating and not wanting to gain weight, these episodes are known as purging and are performed through vomiting, misusing laxatives, diuretics, enemas or other medications. The individual may also perform non-purging methods such as excessive exercise following bingeing or fasting.
• Cycles of bingeing and purging must occur at least once a week for a period of three months or more.
• When evaluating him or herself, the person is fixated on their weight and body shape, to the point where their emotions and happiness are influenced by their personal opinion of their body image.

The level of severity of bulimia will be determined according to the number of times the person purges a week. Should the patient not meet all of the above requirements, he or she may still have an eating or mental disorder and will need to be further evaluated in order to receive the correct treatment for their specific condition.

What is the treatment for bulimia?

Psychotherapy has proven to be a more effective means of treatment for bulimia in comparison to pharmaceutical drugs alone, however, these two treatment forms are often combined in the treatment of bulimia. Psychotherapy, also known as talk therapy, helps the individual suffering from bulimia to deal with their symptoms, emotions and patterns of behaviour and identify ways to change these.

A number of patients will undergo psychotherapy sessions coupled with pharmaceutical intervention such as being prescribed antidepressants. The treatment approach for bulimia is likely to include the patient, their loved ones, their medical specialist or primary care doctor, as well as a mental health professional and possibly a dietician who aids in treating eating disorders.

The information below describes the various methods of treatment for bulimia:

Psychotherapy

Once the patient has been diagnosed as bulimic, a mental health professional will begin sessions of psychotherapy to aid in alleviating bulimia associated symptoms of anxiety, stress or depression and attempt to halt the bine-purge cycle entirely, as well as reduce the chances of relapse in the future. This is done through helping the individual to express their issues and thoughts on their condition and address their current or past stressors in life.

Cognitive behavioural therapy (CBT) is a form of psychotherapy and aids in the aforementioned goals of therapy. In CBT, the therapist involved will use three different techniques to achieve the aforementioned goals of treatment:

1. The didactic component – This technique is the usually the first phase of CBT treatment and will help to create positive goals for the therapy sessions and promote the patient’s participation in the treatment process.
2. The cognitive component – This phase helps in identifying the assumptions and thoughts that may influence bulimia related behaviours, focusing on the thoughts that play a direct role in the negative behaviour triggers associated with bingeing and purging. The binge-purge cycle is fuelled by negative emotions. Certain stressful or negative situations in the affected person’s home or family may trigger bulimic episodes.
3. The behavioural component – This phase will employ behaviour-modification techniques in order to help the individual to learn effective strategies for dealing with various issues. During the cognitive component of therapy, the individual will learn to identify the stressors that influence their eating disorder, following this, they will learn to alter their behaviour and reactions to these triggers.

Family therapy is also used for parents to help a child (who is likely to be an adolescent) suffering from bulimia and develop techniques to help them to maintain a healthy and normal life. This form of treatment will typically take place in three phases:

• PHASE 1: Initially, the patient and their family will work with the therapist to help the individual to maintain a proper intake of food and limit any negative ways of ridding themselves of the calories, i.e. halting their means of purging.
• PHASE 2: Once the education on appropriate food intake and elimination of purging, or non-purging has been taught it must be applied and the patient will be encouraged to control their binge-purge cycle and to take responsibility and maintain proper eating habits, while also refraining from purging habits.
• PHASE 3: During the final phase of family treatment, other general life issues that the adolescent may be dealing with will be addressed, as well as the impact that their bulimic actions have on their everyday life, family and personal development. This may involve discussing both past and present issues in the family.
  
  Some families find this to be a more invasive form of treatment and feel uncomfortable in discussing such problems with ‘strangers’, however, discovering the root cause of bulimia and attempting to allow the patient to see the effect he or she has on their family is often an effective means of getting them closer to recovery. The individual may not realise the effect that they are having on their family or loved ones and that they are adversely impacting their lives with burdening thoughts of worry regarding the patient’s health and emotional state.

Nutritional counselling

Dieticians and other health care professionals may create an eating plan for the patient, in order to assist them to reach a healthy weight, practice good nutrition and stick to healthy eating habits on a long-term basis.

This form of treatment is performed in conjunction with therapy, as well as the prescription of medication and has been known to help decrease the patient’s need to binge and purge. The idea is to create a program that will give the patient what they need in terms of nutrition, but also provide them with food that should combat their cravings and binge eating behaviours.

Dieticians have to be careful so as to not restrict the individual from certain foods as restrictive eating and dieting may have led to their eating disorder in the first place, therefore, the professional will need to work closely with the patient and their therapist to ensure the eating plan is working. The eating plans will also consist of healthy foods to possibly prevent any feelings of guilt associated with eating junk food.

 

Medications

Pharmaceutical treatment of those with bulimia often involves the prescription of antidepressants along with psychotherapy to help balance the patient’s serotonin levels.

The following antidepressants are useful in the treatment of bulimia:

• Selective Serotonin Reuptake Inhibitors (SSRIs) – These drugs are the most commonly prescribed forms of antidepressants and function through increasing serotonin levels. Serotonin has number of vital functions in the body, it aids in controlling bowel movements and is thought to regulate happiness, anxiety and overall mood.
  
  Examples of some SSRIs include:
  • Citalopram (Celexa)
  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil, Paxil CR)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) – These forms of antidepressants increase both norepinephrine and serotonin levels in the brain by inhibiting the reabsorption of these chemicals. Norepinephrine is a stress hormone and neurotransmitter, sending messages from the brain to the body. The hormone helps in situations of stress through increasing the force of the contraction of skeletal muscle, as well as the force and rate at which the heart contracts. Norepinephrine aids in regulating blood pressure and is also used in the treatment of a number of mental health disorders to regulate mood.
  
  Some types of SNRIs include:
  • Desvenlafaxine (Pristiq, Khedezla)
  • Levomilnacipran (Fetzima)
  • Venlafaxine (Effexor XR)
  • Duloxetine (Cymbalta)
• Tricyclic antidepressants (TCAs) – These are some of the earliest types of antidepressants used in the treatment of bulimia. They function similarly to other antidepressants in effecting changes in the chemistry of the brain and the communication between the neurotransmitters to regulate mood and ease symptoms of depression.
  
  Some types of TCAs include:
  • Nortriptyline (Pamelor)
  • Imipramine (Tofranil)
  • Protriptyline (Vivactil)
  • Desipramine (Norpramin)
• Monoamine Oxidase Inhibitors (MAOIs) – These were the first class of antidepressants to be developed and function through elevating the levels of dopamine, serotonin and norepinephrine in the brain by blocking the effects of an enzyme known as monoamine oxidase. This enzyme breaks down these hormones and when it is inhibited, the concentrations of dopamine, serotonin and norepinephrine will increase.
  
  Some types of MAOIs include:
  • Rasagiline (Azilect)
  • isocarboxazid (Marplan)
  • tranylcypromine (Parnate)

Hospitalisation

Bulimia is usually treated effectively without hospitalisation. However, if the patient suffers from a more severe form of the eating disorder (i.e. bingeing and purging multiple times a week) he/she may risk serious health complications and require hospital-based treatment and care. There are some hospital programs for eating disorders that offer day patient treatment.

Some sufferers may be referred to a rehabilitation centre by their doctor or therapist. Rehab centres will involve integrated medical teams of experts working with the patient in a more relaxed setting than a hospital, these are known as inpatient treatment facilities. The medical team on staff can keep an eye on the patient 24/7, ensure that they eat appropriately and do not purge afterwards, help him or her to establish healthy eating habits and encourage the patient to attend therapy sessions alone and/or with other patients in a group setting.

Lifestyle and home remedies for bulimia

It is not suggested that bulimia is treated purely at home without first seeking professional medical diagnosis and treatment. However, there are some lifestyle and home care tips that can help improve the symptoms of the condition after professional treatment is issued (it is important to always speak to your doctor first before partaking in lifestyle and home remedies as he or she may have specific recommendations for the individual case):

• Getting the right food and nutrition – If the individual is not eating correctly and is constantly purging, then the body will be ridding itself of much-needed nutrients. It is advised that the person eats regularly and does not restrict their food intake, this is usually the first and most difficult step in treating bulimia.
• Sticking to the treatment plan – It is vital that the sufferer does not skip any therapy sessions, sticks to their meal plan and takes any medication that has been prescribed to them.
• Learning more about the condition – The more knowledge someone has about bulimia, the more they can understand eating disorders, their effects on body and possible health complications as well as how to deal with them emotionally. Friends and loved ones should also educate themselves on the condition by reading through the information offered in this article and speaking to medical professionals.
• Staying in touch – Bulimia is a very private condition wherein the sufferer will binge and eat in private and try their best to not let anyone know they are suffering. However, patients are advised to keep their friends and loved ones close to offer them the support they will need for recovery. This also includes staying in touch with and attending regular check-ups with their doctor and sessions with their therapist, as well as regular appointments with the various members of the medical team involved.
• Being cautious with exercise – A method of purging for those with bulimia is exercising excessively, however, during treatment, patients will need to speak to their doctor about the appropriate amount of exercise they should be getting, if any at all. Some doctors may recommend that the patient avoids exercise so as to not ‘overdo it’.

Alternative medicine

There are several different herbal products and dietary supplements such as holy basil and catnip that are used to treat overall health and stress management, however, these do not treat bulimia specifically and are not recommended by medical doctors.

Homeopathy and acupuncture are methods that are used by a number of people suffering from bulimia. Bear in mind, these methods do not cure the condition and there is no medical evidence to support their efficacy. It is advised that patients speak to their doctors first before looking at any alternative medicines as forms of treatment.

Stress relievers such as massage, breathing techniques and meditation are often beneficial in helping sufferers to deal with any stress and anxiety associated with bulimia. 

Coping advice for parents dealing with a bulimic child (adolescent)

Parents who are dealing with a child that is bulimic may blame themselves for their child’s eating disorder, however, eating disorders tend to have a number of different causes and someone’s style of parenting is not generally considered a primary cause. Instead of focussing on personal guilt and blame, parents will need to focus on their child and helping him or her to overcome their condition.

The below are some suggestions that may help in supporting a child with an eating disorder:

• First and foremost, parents need to realise that bulimia is a real condition and is not a simple one at that. Bulimia involves intense feelings of guilt and issues with body image that the individual has to deal with, and they will often need to do most of this alone. Placing guilt, stress or anxiety on a child may only serve to further aggravate the condition. Getting help for a child suffering from bulimia is a necessity, and support from parents is vital for recovery.
• Parents are encouraged to speak to their child about what they can do to help them. This includes planning activities, attending therapy sessions or just spending time with them.
• Parents should listen to their child and allow for him or her to express their feelings, ensuring that they do not patronise or belittle their child’s emotions in any way.
• Parents need to inform their child about any concerns they may have for his or her wellbeing, but this needs to be done without placing any blame on the child.
• Parents should schedule regular meal times for the family as routine as structure may help with binge eating.

Eating disorders affect the entire family and take a toll on the family dynamic. Professional counselling may also be an option for parents and loved ones dealing with someone with bulimia. There are also a number of community and online support groups for parents dealing with children with bulimia.

Course and prognosis of bulimia

Bulimia may only last for a short period of time, for example, the condition may arise from a certain stressful situation in life and continue until the stress is dealt with. In other cases, the eating disorder may continue for a number of years or if untreated, for life. Roughly one quarter of individuals with the condition will improve without treatment, however, with treatment more than half of the patients will recover¹².

Bulimia, even after treatment and seeming resolution, may return, therefore a number of healthcare professionals will recommend maintenance treatment. In long-term studies conducted on patients in extended recovery programs, about 70 percent of subjects stopped having symptoms of the condition entirely¹². Others tended to struggle with eating issues in varying degrees of severity.

With accurate treatment, bulimia has higher chances of improving, with the prognosis of the condition having a greater chance of success if the illness is treated early in its development. The prognosis of bulimia is adversely affected if the patient has pre-existing psychiatric issues¹² such as mood disorders, OCD (obsessive-compulsive disorder) or a personality disorder. The outcomes in these instances are, however, often greatly improved if the individual seeks treatment for their mental condition, as well as bulimia.

Is it possible to prevent bulimia?

Although there is no proven way to prevent bulimia, there are ways that loved ones and parents can lead their children, friends or partners towards healthier behaviour in terms of body image and eating. The below explains some techniques to aid in the prevention of bulimia should you think your child or loved one may be at risk:

• Reinforcing and fostering a healthy body image in children
  • Ensure that your child does not obsess over a specific body type as an ideal and try to facilitate an attitude that regards all shapes and sizes as attractive. Speak to a therapist or mental healthcare professional in regard to how to do this
  • Innocent teasing, particularly by male family members may be a contributing factor to the onset of eating disorders, especially in female children. Male members of the family should be made aware of this fact and continue to be mindful of it when interacting with young children.
• Talking to your child or loved one about any stressors that they may have and how you can help with these can be effective in helping to resolve these emotional issues.
• Do not disregard any feelings, mood disorders and issues with food as unimportant. If you suspect that your loved one or child is experiencing any issues that may lead to the development of an eating disorder, speak to your doctor or mental healthcare professional as he or she will be able to identify the symptoms of bulimia early.

The challenges of treatment for those with bulimia

The majority of individuals suffering from bulimia will seek treatment or have a loved one encourage them to do so. Once treated they are likely to recover from their eating disorder, however, some people find that the symptoms do not disappear entirely. The cycles of bingeing and purging tend to come and go over time, these unhealthy habits of eating will depend on the individual’s life circumstances and often emerge when the person is intensely stressed or experiences something traumatic.

Should the person find themselves back in a cycle of bingeing and purging, they may find that a ‘booster’ or ‘recap’ session with their therapist helps them to deal with their current crisis and stops the eating disorder from spiralling out of control once again. In these sessions, positive coping mechanisms for dealing with the condition, some of which they may have forgotten since their initial treatment, may be re-taught and reinforced. Relapses in bulimia are common as the condition is a long-term one that is fuelled by various mental and personal issues that the sufferer may be battling with at any given time.

 

^References:

^{12. NIH. 2005. Does "excessive" or "compulsive" best describe exercise as a symptom of bulimia nervosa? Available: https://www.ncbi.nlm.nih.gov/pubmed/15991218 [Accessed 24.11.2017]}