Eating disorders are undoubtedly a subset of pathologies which have motivated the interest of healthcare professionals and laypersons alike. In fact, terms such as “anorexia” or “bulimia” have been taken from their specialized or technical niche, to forge popular knowledge and to consolidate in everyday language.
Perhaps most striking of these is the process of physical / mental decline associated with the restriction of essential foods, or the dangerous “relationship” that patients manage to have with their own body shapes. Other symptoms, such as binge eating or purges, also appear as violent acts of aggression against the body itself and its functions.
The truth is that we are facing a very serious health problem which is seriously endangering the lives of those who suffer from it and which has very alarming death rates. His journey, which spans many years, can be seen splashed with other mental disorders that transform his face and cloud his prognosis.
In this article, we will detail, more precisely, bulimia nervosa comorbidities. This is a diverse group of clinical conditions whose knowledge is fundamental to providing the rigorous therapeutic approach it needs, both in a human and scientific sense.
Characteristics of bulimia nervosa
Bulimia nervosa is a serious mental health problem, but with profound resonances on organic variables. It is included in the category of eating disorders, along with others, such as anorexia nervosa.
It is most often manifested by constant preoccupation with food and diet, as well as episodes of overeating. (Binges) who are experienced in absolute loss of control. Now the individual reports feeling unable to interrupt the behavior or that their awareness of the amounts or types of food being consumed is dissolving. This is why a strong feeling of guilt (which goes beyond the fear of gaining weight) would also appear.
At the same time, and in order to stop the emotional discomfort that floods them in these trances, many of them plan to set up compensatory behavior. It can vary and includes self-induced vomiting to improper use of laxatives or uncontrolled fasting. These strategies aim to regulate difficult conditions, which the person perceives as overwhelming and with which he has great difficulty to struggle. Ultimately, this would lead to a relief that would reinforce the cycle of the problem (“eliminate” a difficult emotion), but unfortunately keep it going over time (long term).
Bulimia nervosa, like other dietary conditions, has many clinically important comorbidities. In fact, An estimated 92% of patients report at least one other mental health problem (Although they can be complex combinations) at a later point in your life. This phenomenon would be a major problem, in which it should be considered as a therapeutic plan which adapts to the peculiarity of each case (because it highlights the enormous variability of the psychopathological expression resulting from its competition with other troubles).
Comorbidities of bulimia nervosa: common disorders
Here are the comorbidities that occur most frequently in the context of bulimia nervosa. Of all these factors, the most important are mood, drug use and anxiety.
However, it should be noted that a high percentage also report typical symptoms of anorexia nervosa throughout their lifeAs there is a lot of experimental evidence that transdiagnostic links are observed between the two (the clinic varies from one to the other at different times). The consequence of the latter is that it may not be easy to distinguish what each patient is suffering from during the scan, as they fluctuate with some erraticism.
Let’s see which are, according to the current state of the matter, the most relevant comorbidities of bulimia nervosa
Major depression is arguably the most common mental disorder in people with bulimia nervosa.. Its vital prevalence is 75% and results in a labile mood and / or a very noticeable increase in suicidal ideation. There are different studies suggesting that major depression in adolescence is an essential risk factor for the onset of bulimia, the first of which precedes the other in time, especially when its causes worsen in an explicit rejection of the group. of peers.
The relationship between bulimia nervosa and depression appears to be two-way, having postulated very different explanatory theories around the subject.
The negative effects model is one of the most widely used and suggests that Binge eating binge reportedly aims to reduce mental illness linked to mental disordersWhile inducing vomiting, one would seek to minimize the feeling of guilt (and anxiety) resulting from these episodes of overeating. It’s a recurring cycle that accentuates the negative feeling at the root of the problem, making it easier for it to get worse or for other comorbidities to appear.
At the same time, food restriction efforts are known to decrease the level of tryptophan in the human body (precursor of the neurotransmitter serotonin), which chemically accentuates the sadness that sleeps after this serious comorbidity. If concomitant depression is identified, pharmacological and psychological treatment strategies should be orchestrated, avoiding the use of the bupropion compound when possible (as it could precipitate epileptic-like seizures in people who report having binge eating. ).
2. Bipolar disorder
Bipolar disorder (type I or II) occurs in 10% of bulimia cases, especially in the most severe imbued. Symptoms include recurrent and debilitating episodes in which mood is expansive, irritable and elevated (mania and hypomania) or depressed; next to periods of euthymia (stability).
Cases have been described in which the affective lability of bulimia has been confused with the characteristic expression of bipolar disorder, producing a misdiagnosis that delays receipt of adequate help.
When this comorbidity occurs, it should be kept in mind that lithium therapy should be monitored more frequently than in other patients., Vomiting which can reduce potassium levels and interfere with kidney function (leading to very dangerous increases in drug levels).
As such a substance is excreted by the kidneys, this situation results in potentially fatal toxicity. It may also happen that the patient rejects work in the face of the possibility of weight gain, as it is one of the most feared situations for people suffering from the disorder.
3. Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) can occur frequently in people diagnosed with bulimia nervosa, especially since they share many facilitating traits (such as a tendency to rumination and impulsivity). It is believed that between 8 and 33% will report it at some point in their life cycle, although it is more common in anorexia nervosa. (Up to 69% of cases). They do not yet know the specific causes of this comorbidity; but it relates to a less favorable course, to the presence of repetitive ideas and to an accentuated tendency to self-induced vomiting.
The clinical expression of OCD requires intrusive, difficult to control and recurring thoughts to occur; which generate such a degree of emotional distress that they can only be managed by compulsive acts or cognitions, and they come to adopt the properties of a ritual. In this sense, many authors have considered that mental content on self-induced weight gain and vomiting could play the role of obsessions / compulsions in bulimia (Respectively), which would resonate in a clear analogy between this and TOC.
Studies on this topic do not suggest an order of presentation for this comorbidity, so it can be initiated with both OCD and bulimia nervosa. However, in many cases, obsessive and compulsive symptoms persist even after the eating disorder has resolved. totally.
4. Anxiety disorders
Anxiety problems are very common in bulimia nervosa. Panic disorder (11%) triples its prevalence compared to that observed in the general population, Although this is a difficult relationship to explain. It tends to be expressed as sudden, unpredictable episodes of intense physical activation, mediated by the sympathetic nervous system, and functioning with symptoms perceived as aversive (tachypnea, sweating, tremors, tachycardia, and near death). Their presence accentuates the number of binge eating attacks, as well as the purgative responses that follow them.
Social phobia was also found in a high percentage of patients (20%) with bulimia nervosa, who see an increased fear that others will decide to mock or criticize details of their outward appearance that they perceive as unwanted. .
This comorbidity increases resistance to appearing in public while eating or drinking; in addition to the fear and apprehended anticipation of situations in which one may be exposed to negative judgments, criticisms and / or evaluations. There is a clear consensus that certain parenting styles (especially those related to dangerous inclinations) can precipitate their onset in these patients.
Specific phobias (towards certain stimuli and situations) triple their prevalence (vital) in this disorder (from 10% to 46%), compared to what is usually estimated by the general population. In this case, the phobic stimulus is usually both animal and environmental., Thus annexing to the pre-existing aversion (specific to such an image) to weight gain. All specific phobias tend to dip their origins into a specific experience (aversive tone), although they are usually maintained by deliberate avoidance mechanisms (negative reinforcement).
To finish, also highlights the high incidence of generalized anxiety disorder, which is expressed as a recurring concern for a myriad of everyday situations. While it is true that in bulimia nervosa there is often perpetual rumination of food, due to the co-morbidity the process would extend to other very disparate issues.
It seems to be more common in the use phases of the purges, especially in adolescence, although it is sometimes born in childhood (up to 75%). These patients may have a more pronounced tendency to avoid.
5. Post-traumatic stress disorder
13% of people with bulimia report the cardinal symptom spectrum of post-traumatic stress disorder, a response that the person then shows as being exposed to a critical or deeply unwanted event.
Specifically, re-experimentation (thoughts / images that reproduce events directly associated with the ‘trauma’), nervous system hyperactivation (constant alert state) and avoidance (efforts to escape / escape in the face of impending stimuli / imminent or facts related to the past). In particular, Child sexual abuse is a risk factor for this comorbidity in people with bulimia, as in the general population.
In both cases (bulimia and PTSD), it is very difficult to deal with the effects on automatic negative thoughts or images of threatening content. So much so that there are hypotheses suggesting that post-traumatic re-experimentation is in fact an attempt by the nervous system to expose itself to a real event that it could never process (For emotional intensity), be the end of it (flashbacks, for example) overcome the pain associated with it.
This mechanism was used to explain intrusive thinking about food and for the trauma itself, so it could be a common mechanism.
People with co-morbidities examined are known to have more intense ruminative thoughts, a worse response to pharmacologic-type treatment, a greater tendency to binge eating, and feelings of guilt on a large existential scale. Most likely, PTSD precedes bulimia over timeIt is therefore generally considered to be a significant risk factor.
6. Substance dependence
Substance Use Is One Of The Most Important Problems For People With Bipolar Disorder. Many potential mechanisms involved have been described in the literature on such a relevant subject over the years, namely: excessive consumption in order to reduce body weight (especially drugs with a stimulant effect, which activate the sympathetic nervous system by modifying the process by which stores / consumes calories), a deficit in impulse control (which is shared with binge eating) and a decrease in feelings of guilt secondary to overeating.
Other authors suggest that people with bulimia and substance dependence may suffer deregulation of the brain reward system (Formed by the nucleus accumbens (NAC), the ventral tegmental area (VTA) and its dopamine projections to the prefrontal cortex), a deep network of neurological structures involved in motor responses to appetite stimuli (and which can therefore be “activated” as a result of overeating and / or drug use). This is why bulimia in adolescence is a neurological risk factor for addiction during this period.
Anyway, it appears that bulimia precedes the onset of addiction, and it is the moments after the binge that present the greatest potential risk. (For consumption). Finally, other authors have noted that drug use increases impulsivity and reduces inhibition, thus weakening the effort to actively prevent episodes of overeating. As can be seen, the relationship between these two problems is complex and two-way, so substance use can be seen as a cause and a consequence of binge eating (depending on the context).
- O’Brien, K. and Vincent, N. (2003). Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence and cause and effect relationships. Journal of Clinical Psychology, 23, 57-74.
- Woodside, B. and Staab, R. (2006). Management of psychiatric comorbidity in anorexia nervosa and bulimia nervosa. CNS Drugs, 20, 655-63.