Bulimia nervosa, factors of personal vulnerability

Bulimia nervosa, factors of personal vulnerability

Bulimia nervosa is characterized by recurrent episodes of uncontrolled binge eating. These episodes of voracious intake are often followed by the use of methods to control weight gain. These methods of weight control often achieve in the form of provoked vomiting, excessive exercise, restrictions on food and the use of laxatives and diuretics. Bulimia was first introduced into the DSM-III diagnostic system (APA, 1980) as its own diagnostic category.

The most appropriate description of bulimia has been discussed over the next 14 years. The diagnostic criteria of DSM-V describe two types of bulimia nervosa, the purgative and non-purgative types. The purgative subtype describes patients who fight binge eating through regular episodes of self-induced vomiting or abuse of laxatives or diuretics. The non-purgative subtype describes patients who fast or exercise excessively, in order to compensate for episodes of docking behavior, but who do not normally abuse laxatives, diuretics or do not use self-induced vomiting to Control body weight. In DSM-V, a diagnosis of anorexia nervosa prevails over another of bulimia nervosa.


  • 1 Diagnostic characteristics of bulimia
  • 2 types of bulimia
  • 3 Explanatory models
  • 4 Personal vulnerability factors
  • 5 Bulimia intervention
  • 6 Main therapeutic objectives for bulimia

Diagnostic characteristics of bulimia

  1. Presence of recurrent binge eating: characterized by food intake in high quantity and in a short space of time, with a feeling of loss of control over intake.
  2. Inappropriate compensatory behaviors, repeated so as not to gain weight: excessive use of laxatives, diuretics, enemas, vomiting provocation, exaggerated exercise.
  3. Binge eating and compensatory behaviors occur at least twice a week for a period of 3 months.
  4. Self-assessment is heavily influenced by weight and body silhouette.
  5. The alteration does not appear exclusively in the course of anorexia nervosa.

Types of bulimia

  • Purgative type. During bulimia nervosa, the patient causes vomiting, uses laxatives, enemas or excess diuretics.
  • Non-purgative type. Compensatory behaviors are fasting or intense exercise.

Clinical complications occur in 40% of patients, suicide attempt being the most common risk of death of these patients reaching 3%, although lower than in anorexia nervosa.

The most frequent somatic alterations occur in the digestive system, the oral cavity being the most affected. They present erosions of dental enamel, especially the inner side of incisors and canines, due to the acidic pH of gastric juice and its continuous action on enamel. Of equal pathogenesis is the presence of gingivitis, pharyngitis and cheilitis. Occasionally, parotid hypertrophy has been observed, related to vomiting and causing increased plasma amylase; It is usually symmetrical and painful, disappearing at the end of the process in most cases. The alterations at the level of the esophagus They range from the appearance of esophagitis to Mallory-Weiss syndrome. The capacity of the stomach is greatly increased, leading to cause acute gastric dilation with local ischemia phenomena that can lead to gastric perforation. The abuse of laxatives or enemas can produce rectorragias, which require a differential diagnosis with inflammatory bowel disease.

Likewise, cases of acute pancreatitis related to compulsive food intake have been described, cardiac complications, which are not exceptional, with mitral valve prolapse being the most frequent alteration, although cardiac arrhythmias are also observed. Other frequent complications are poisoning due to abuse of emetics, diuretics and laxatives. However, osteoporosis is of rare presentation. It is noteworthy the possibility of the association between bulimia nervosa and diabetes mellitus (DMID), describing Garfinkel in 1987 a prevalence of 6.9% of bulimia in DMID, since these patients when manipulating insulin doses as a method to eliminate excessive Calorie intake presents a risk of ketoacidotic coma and poor control. At present, the importance of investigating an eating behavior disorder in all patients with poorly controlled DMID is stressed.

Explanatory Models

In bulimia nervosa binge eating often develops after a period of food restriction, which results in hunger, a voracious appetite and energy deprivation. The interruption of such food limitation is often triggered by emotional distress or the intake of prohibited foods. Purging behavior decreases the anxiety that results from binge eating. That behavior also produces a decrease in nutrients to the body and can reduce the base metabolism (Bennett, Williamson and Powers, 1989). Over time, a cyclical pattern of restriction of food, bingeing and purging behaviors often develops, and cognitive behavior therapy is designed to break this cycle of behaviors. From the cognitive-behavioral perspective, purging behaviors and dieting are negatively reinforced by decreasing anxiety regarding weight gain (Williamson, 1990). Binge eating is considered to be maintained by a reduction in negative affect, in addition to the pleasant effects of eating (Heatherton and Baumeister, 1991). Recently, theories of body image of eating disorders have focused more on body image disturbance as the main motivation for disturbed eating behavior.

The cognitive model of bulimia of McPherson (1988) starts from the basic premise that Bulimia is a consequence of certain cognitive distortions derived from beliefs and values ‚Äč‚Äčabout body image and weight. The lack of self-control of the diet that appears in the bulimic patient (and in the anorexics with bulimic problems) would be related to an extreme need for control of these people in certain areas (school performance, body control, etc.). This cognitive vulnerability could materialize in the basic belief or assumption: "Weight and body image are fundamental for self-assessment and social acceptance". With this belief, a series of cognitive distortions would be interrelated, highlighting: 1) Dichotomous thinking (Polarization): Divide reality into extreme and opposite categories without intermediate degrees; eg, "Fat vs. Skinny"; 3) Personalization: It relates the events to the conduct itself or as referring to itself without a real basis (eg, in a socially skilled girl who believes: "They reject me because of my appearance"); 5) Over-estimation of body image: They are perceived as thicker than they are; 6) Global and general self-assessment:

They are estimated and valued globally compared to extreme social standards (eg, "If I don't have the body of a model I am worthless").

The lack of control of the intake and the restriction of the diet that occur in the form of cycles would be related to the previous cognitive distortions. These, in turn, would interact with the biological needs of hunger generating important conflicts that would lead to these uncontrolles and the return to control attempts restricting the diet. In addition, as these people lack better coping strategies, both the need for hunger and other sources of stress (eg, social situations) would act as predictive signs of threat producing a state of anxiety that would act as "cognitive distraction" and as " negative reinforcement "reducing anxiety. The self-induced vomiting mechanism would respond to the same process described.

In summary, the two models presented are based on the importance of social modeling of body image, personal vulnerability (meanings in relation to weight and social success, with social incompetence), cognitive distortions and reinforcement role as coping feedback of strategies Very limited personnel.

Personal vulnerability factors

(1) Perfectionist attitudes:
(2) Personal meaning about

  • Weight / body image
  • Perfectionism
  • Success / self-assessment
  • Low tolerance to frustration

(3) Lack of social skills.
Activating situation

(1) Acute or chronic stressors of social or mood type.
(2) Feelings of hunger

Coping style

(1) Intake control
(2) Use of laxatives or vomiting.

Anorexic symptoms and family pressure

(1) Short term: anxiety reduction, feeling of control
(2) Long term: increased discomfort, guilt, dysphoria.

Bulimia intervention

A series of psychological therapies have been developed for the treatment of anorexia and bulimia nervosa. Research on these treatment approaches has occurred since the 1970s. Studies with a control group on these approaches have been carried out mainly with patients with bulimia, due to the health risks associated with assigning patients with anorexia to placebo or untreated groups. Most of the research on treatment has focused on cognitive-behavioral and pharmacological therapies (Williamson, Sebastián and Varnado, in press). Structured short-term therapy, such as interpersonal therapy, has also been evaluated in recent years.

Rosen (1992) hypothesized that anorexia and bulimia nervosa are manifestations of a general body image disorder similar to what would be body dysmorphic disorder. This distortion of body image can be maintained by the attention bias towards information consistent with the beliefs that the body figure itself is not attractive. From this perspective, behavioral changes arise, such as avoiding using provocative dresses, restricting socialization and avoiding sexual intimacy, resulting from efforts to reduce body dysphoria. From these cognitive behavioral approaches, a series of treatment techniques have been tested. These approaches are summarized below. Behavioral and cognitive techniques are written separately. The reader should remember that most studies on CBT have combined a series of these behavioral and cognitive techniques.

Main therapeutic objectives for bulimia

The primary objective of the patient is the achievement of an idealized body weight and figure. This leads him to make extreme diets, rigidly, which predisposes him to occasional loss of control (binge eating). Given the absolute value they give to thinness, they undertake - also extreme - forms of compensation for such binge-eating, such as self-induced vomiting. In turn, self-induced vomiting facilitates binge eating because the belief in its effectiveness in getting rid of ingested food reduces the natural tendency not to overeat. Excessive concern about weight and figure, particularly the tendency to make their self-esteem depend on them, promotes extreme diet and, therefore, maintains the whole problem. Thus, the typical cognitive alteration of BN consists of a series of overvalued ideas about weight and figure.

Depending on the models presented above, we can extract common therapeutic objectives for eating disorders:

  1. Develop realistic attitudes / beliefs about body image and weight;
  2. Establish a normal weight pattern;
  3. Reduction of uncontrolled intake, vomiting and laxative abuse;
  4. Improve overall personal functioning: self-acceptance, coping with anxiety and social functioning and,
  5. Set the motivation for the treatment.

Below you can see an infographic where the key aspects of this disease are summarized.

Related tests
  • Depression test
  • Goldberg depression test
  • Self-knowledge test
  • how do others see you?
  • Sensitivity test (PAS)
  • Character test