The 6 Most Important Comorbidities Of Bulimia Nervosa
Eating disorders are, without a doubt, a subset of pathologies that have motivated the interest of health professionals and lay people. In fact, terms such as “anorexia” or “bulimia” have been extracted from their specialized or technical niche, to become part of popular knowledge and consolidate themselves within everyday language.
Perhaps what is most striking about these is the process of physical/mental decline associated with the restriction of essential foods, or the dangerous “relationship” that patients maintain with their own body silhouette. Other symptoms, such as binge eating or purging, also emerge as clear acts of aggression towards one’s own body and its functions.
The really true thing is that we are facing a very severe health problem, which seriously compromises the lives of those who suffer from it and which registers very alarming mortality rates. Its course, which extends over many years, can be punctuated by other mental disorders that transform its face and cloud its prognosis.
In this article we will detail, specifically, comorbidities of bulimia nervosa They are a varied group of clinical conditions whose knowledge is basic to provide the therapeutic approach with the rigor it needs, both in a human and scientific sense.
Bulimia nervosa is a severe mental health problem, but with deep resonances on organic variables. It is included in the category of eating disorders, along with others, such as anorexia nervosa.
It usually manifests itself as a constant concern about food and eating, as well as episodes of overeating (binge eating) that is experienced from the absolute loss of control. At these moments the individual reports that he feels unable to interrupt the behavior, or his awareness of the amounts or types of food consumed dissolves. That is why, in addition, a strong feeling of guilt would arise (which rises above the mortal fear of gaining weight).
In parallel, and with the aim of stopping the emotional discomfort that floods them in these moments, many of them consider putting into practice some compensatory behavior. This can be diverse, and includes everything from self-induced vomiting to the misuse of laxatives or uncontrolled fasting. These strategies are intended to regulate difficult emotions, which the person perceives as overwhelming and with which it is very difficult to deal. Finally, this would achieve relief that would reinforce the cycle of the problem (“eliminate” a difficult emotion), but that unfortunately would maintain it over time (in the long term).
Bulimia nervosa, like other eating disorders, presents many comorbidities of clinical relevance. In fact, It is estimated that 92% of patients will report at least one other mental health problem (although they may be complex combinations) at some later point in their life. This phenomenon would represent a first-order problem, in which a therapeutic plan that adapts to the peculiarity of each case would have to be considered (since it highlights the enormous variability in the psychopathological expression resulting from its concurrence with other disorders).
Comorbidities of bulimia nervosa: common disorders
The comorbidities that most frequently arise in the context of bulimia nervosa are highlighted below. Of all of them, the most important relate to mood, drug use and anxiety.
However, it must be noted that A high percentage also reports symptoms of anorexia nervosa throughout their lives, since there is abundant experimental evidence that transdiagnostic links are seen between both (the clinical symptoms vary from one to the other at different times). The consequence of the latter is that it may not be easy to discriminate which one each patient is suffering from during the examination, since they fluctuate with certain erratics.
Let’s see which are, according to the current state of this matter, the most relevant comorbidities of bulimia nervosa.
1. Depression
Major depression is, without a doubt, the most common mental disorder in people who suffer from bulimia nervosa Its vital prevalence rises to 75% and is expressed as a labile state of mind and/or a very notable increase in suicidal ideation. There are different works suggesting that major depression during adolescence is an essential risk factor for the appearance of bulimia, the first of which precedes the other in time, especially when its causes delve into an explicit rejection of the peer group.
The relationship between bulimia nervosa and depression seems to be bidirectional, with very different explanatory theories having been postulated on the matter.
The negative affect model is one of the most used, and suggests that The binge eating typical of bulimia would aim to reduce the psychological discomfort linked to the mood disorder, while inducing vomiting would seek to minimize the feeling of guilt (and anxiety) that results from these episodes of overeating. This is a recurring cycle that fuels the negative feeling at the base of the problem, making it worse or causing other comorbidities to emerge.
In parallel, it is known that efforts to restrict food decrease the level of tryptophan in the human body (precursor of the neurotransmitter serotonin), which chemically accentuates the sadness that lurks after this serious comorbidity. If concomitant depression is identified, both pharmacological and psychological therapeutic strategies should be orchestrated, avoiding the use of the compound bupropion when possible (since it could precipitate seizure-type attacks in people who report suffering from binge eating).
2. Bipolar disorder
Bipolar disorder (type I or II) manifests itself in 10% of bulimia cases, especially in the most serious cases. Symptoms include recurrent, disabling episodes in which the mood is expansive, irritable and elevated (mania and hypomania), or depressed ; along with 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 erroneous diagnoses that delay receiving appropriate help.
When this comorbidity occurs, it is necessary to take into account that lithium treatment must be supervised more frequently than in other patients since vomiting can reduce potassium levels and interfere with kidney function (promoting a very dangerous increase in drug levels).
As such a substance is eliminated by the kidneys, this situation implies potentially fatal toxicity. It could also happen that the patient rejects employment due to the possibility of weight gain, since this is one of the situations most feared by those who suffer from the disorder.
3. Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder (OCD) can occur frequently in people with a diagnosis of bulimia nervosa, especially considering that they share many facilitating traits (such as a tendency to ruminate and impulsivity). It is believed that between 8-33% will report it at some point in their life cycle, although it is more common in anorexia nervosa (up to 69% of cases). The specific causes of this comorbidity are not yet known; but it is related to a less favorable evolution, a presence of repetitive ideas and a marked tendency to self-induced vomiting.
The clinical expression of OCD requires intrusive, difficult to control and recurring thoughts to manifest; which generate such a high degree of emotional discomfort that they can only be managed through compulsive acts or cognitions, and which come to adopt the properties of a ritual. In this sense, many authors have considered that mental contents about weight gain and self-induced vomiting could play the role of obsessions/compulsions in bulimia (respectively), which would resonate in a clear analogy between this and OCD.
Studies on this matter do not suggest an order of presentation for this comorbidity, so it can begin with both OCD and bulimia nervosa. However, in many cases the obsessive and compulsive symptoms persist even though the eating disorder has been completely resolved.
4. Anxiety disorders
Anxiety problems are very common in bulimia nervosa. Panic disorder (11%) triples its prevalence compared to what is observed in the general population, although it is a difficult relationship to explain. It tends to express itself as unpredictable and abrupt episodes of intense physical activation, mediated by the sympathetic nervous system, and which presents with symptoms that are perceived as aversive (tachypnea, sweating, tremor, tachycardia and sensation of imminent death). Its presence accentuates the number of binges, as well as the purgative responses that follow them.
Social phobia has also been found in a high percentage of patients (20%) with bulimia nervosa, who have an increased fear that others will decide to mock or criticize details of their external appearance that they perceive as undesirable.
This comorbidity increases resistance to appearing in public while eating or drinking ; in addition to fear and apprehensive anticipation of situations in which one could be exposed to judgments, criticism and/or negative evaluations. There is a clear consensus on the fact that certain parenting styles (especially those linked to insecure attachments) can precipitate its appearance for these patients.
Specific phobias (towards certain stimuli and situations) triple their (vital) prevalence in this disorder (from 10% to 46%), compared to what is usually estimated for the general population. In this case the phobic stimulus is usually both animal and environmental, thus joining the pre-existing aversion (typical of such a condition) to weight gain. All specific phobias usually have their origins in a specific experience (of an aversive tone), although they are usually maintained through mechanisms of deliberate avoidance (negative reinforcement).
Finally, also highlights the high incidence of generalized anxiety disorder, which is expressed as a recurring concern for an endless number of everyday situations. Although it is true that perpetual rumination regarding eating frequently occurs in bulimia nervosa, as a consequence of comorbidity the process would extend to other very disparate issues.
It seems to be more common in the phases in which purges are resorted to, especially in adolescence, although occasionally it is born in childhood (up to 75%). It may be that these patients have a more pronounced avoidance tendency.
13% of people with bulimia report the cardinal symptomatological spectrum of post-traumatic stress disorder, a response that the person shows after being exposed to a critical or deeply adverse event.
Specifically, re-experiencing (thoughts/images that reproduce events directly associated with the “trauma”), hyperactivation of the nervous system (constant state of alert) and avoidance (efforts to flee/escape from the proximity/imminence of stimuli or linked events). to the past). In particular, Childhood sexual abuse is a risk factor for this comorbidity in people with bulimia, as in the general population
In both cases (bulimia and PTSD) there is great difficulty in managing emotions regarding negative automatic thoughts or images with threatening content. This is so much the case that there are hypotheses suggesting that post-traumatic reexperiencing is actually an attempt by the nervous system to expose itself to a real event that it was never able to process (due to the emotional intensity), the goal being (flashbacks, eg) to overcome the pain associated with it.
This mechanism has been used to explain intrusive thinking about food and for trauma itself, and therefore could be a common mechanism.
It is known that people with the aforementioned comorbidity have more intense ruminative thoughts, a worse response to pharmacological treatment, a greater tendency toward binge eating, and feelings of guilt of great existential magnitude. PTSD most likely precedes bulimia in time which is why it is usually considered a notable risk factor for it.
6. Substance dependence
Substance use is one of the most important problems that occur in subjects with bipolar disorder In the literature on such a relevant issue, numerous potential mechanisms involved have been described over the years, namely: abusive consumption whose purpose is to reduce body weight (especially drugs with a stimulant effect, which activate the sympathetic nervous system, altering the process by calories are stored/consumed), deficits in impulse control (which is shared with binge eating) and reduced feelings of guilt secondary to overeating.
Other authors suggest that people who suffer from bulimia and substance dependence could be suffering a dysregulation 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 approaching motor responses to appetitive stimuli (and therefore can be “triggered” as a result of binge eating and/or drug use). This is why bulimia in adolescence is a neurological risk factor for addictions during this period.
In any case, It seems that bulimia precedes the appearance of dependence, and that the moments after binge eating are the ones with the greatest potential risk (for consume). Finally, other authors have pointed out that the use of a drug would increase impulsivity and reduce inhibition, and therefore weaken the effort to actively avoid episodes of overeating. As can be seen, the relationship between these two problems is complex and bidirectional, so that the use of a substance can be considered both a cause and a consequence of binge eating (depending on the context).
