The 6 most important comorbidities of bulimia nervosa

Eating disorders are undoubtedly 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 forge in popular knowledge and consolidate themselves within everyday language.

Perhaps what is most striking of these is the process of physical / mental decline associated with the restriction of essential foods, or the dangerous "relationship" that patients come to have with their own silhouette bodily. Other symptoms, such as binge eating or purging, also appear as clear acts of aggression towards the body itself and its functions.

What is really certain 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 spans 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.

• Related article: "The 10 most common eating disorders"

Characteristics of bulimia nervosa

Bulimia nervosa is a severe 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.

Usually it manifests as a constant preoccupation with food and eating, as well as episodes of overeating. (binges) that are lived from the absolute loss of control. At these moments, the individual reports that he feels unable to interrupt the behavior, or his consciousness about the amounts or types of food consumed dissolves. That is why, in addition, a strong feeling of guilt would arise (which rises above the cerval fear of getting fat).

In parallel, and with the aim of stopping the emotional discomfort that floods them in these trances, many of them consider putting into practice some compensatory behavior. This can be diverse, and includes from self-induced vomiting to misuse of laxatives or uncontrolled fasting. These strategies are intended to regulate difficult affects, which the person perceives as overflowing and with which it is very difficult to deal with. Finally, this would provide relief that would reinforce the cycle of the problem ("eliminate" a difficult emotion), but which would unfortunately maintain it over time (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 can be complex combinations) at some later point in your life. This phenomenon would suppose a problem of the first order, in which a therapeutic plan that adapts to the peculiarity of each case (as it highlights the enormous variability in 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 these, the most important concern mood, drug use and anxiety.

However, it should be noted that a high percentage also report symptoms of anorexia nervosa throughout their lives, since there is abundant experimental evidence that there are transdiagnostic links between the two (the 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 is suffering from each patient during the examination, since they fluctuate with some erratism.

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 up to 75% and is expressed as a labile mood and / or a very notable increase in suicidal ideation. There are different studies suggesting that major depression during adolescence is an essential risk factor for the appearance of bulimia, the first one being the one that precedes the other in time, especially when its causes delve into an explicit rejection of the group of equal.

The relationship between bulimia nervosa and depression seems to be bidirectional, with very different explanatory theories having been postulated on the subject.

The negative affect model is one of the most widely used, and suggests that binge eating typical of bulimia would aim to reduce the mental distress linked to the mood disorder, while the induction of vomiting would seek to minimize the feeling of guilt (and anxiety) that results from these overeating episodes. It is a recurring cycle that fuels the negative feeling at the base of the problem, making it easier for it to get worse or for other comorbidities to emerge.

In parallel, efforts to restrict food are known to decrease the level of tryptophan in the human body (precursor of the neurotransmitter serotonin), which chemically accentuates the sadness that dozes after this serious illness comorbidity. In the event that a 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 seizures of the seizure type in people who report suffering Binge).

• You may be interested: "Types of depression: its symptoms, causes and characteristics"

2. Bipolar disorder

The Bipolar disorder (type I or II) manifests itself in 10% of bulimia cases, especially in the more serious ones. Symptoms include the recurrent and disabling presence of episodes in which mood is expansive, irritable, and elevated (mania and hypomania), or depressed; together with periods of euthymia (stability).

Cases have been described in which the affective lability of bulimia has been confused with the expression characteristic of bipolar disorder, producing erroneous diagnoses that delay receiving help adequate.

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 an eventually fatal toxicity. It could also happen that the patient rejects their employment due to the possibility of weight gain, since it is one of the most feared situations 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 when considering that they share many facilitating traits (such as the tendency to rumination and impulsiveness). It is believed that between 8-33% will refer it at some point in their life cycle, although it is more common in anorexia nervosa (up to 69% of cases). The specific causes for this comorbidity are not yet known; but it is related to a less favorable evolution, a presence of repetitive ideas and an accentuated 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 acts or compulsive cognitions, and that they come to adopt the properties of a ritual. In this sense, many authors have considered that mental content 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 issue 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 fully 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 abrupt and unpredictable episodes of intense physical activation, mediated by the sympathetic nervous system, and that presents with symptoms that are perceived as aversive (tachypnea, sweating, tremor, tachycardia and feeling of death imminent). 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 see increased fear that others will make fun of or criticize details of their outward appearance that they perceive as undesirable.

This comorbidity increases the resistance to show up in public while eating or drinking; in addition to fear and apprehensive anticipation of situations in which they could be exposed to judgments, criticisms and / or negative evaluations. There is a clear consensus on the fact that certain parenting styles (especially those related to insecure attachments) can precipitate their appearance for 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 for the general population. In this case, the phobic stimulus is usually both animal and environmental., thus adding to the preexisting aversion (typical of such a picture) to weight gain. All specific phobias tend to have their origins in a specific experience (of an aversive tone), although they are usually maintained through mechanisms of deliberate avoidance (negative reinforcement).

By last, also highlights the high incidence of generalized anxiety disorder, which is expressed as a recurring concern for endless everyday situations. Although it is true that in bulimia nervosa a perpetual rumination regarding eating occurs frequently, as a consequence of comorbidity the process would extend to other very disparate subjects.

It seems to be more common in the phases in which purges are used, especially in adolescence, although occasionally it is born in childhood (up to 75%). These patients may have a more pronounced avoidance tendency.

• You may be interested: "Types of Anxiety Disorders and their characteristics"

5. Post-traumatic stress disorder

13% of people with bulimia refer to the cardinal symptomatological spectrum of stress disorder post-traumatic, a response that the person displays after being exposed to a critical event or deeply adverse.

Specifically, re-experiencing (thoughts / images that reproduce events directly associated with "trauma"), hyperactivation of the nervous system (constant state of alertness) and avoidance (efforts to flee / escape from the proximity / imminence of stimuli or events related to the past). In particular, Child sexual abuse is a risk factor for this comorbidity in people with bulimia, as well as in the general population.

In both cases (bulimia and PTSD) there is great difficulty in managing affects on negative automatic thoughts or images with threatening content. To such an extent that there are suggestive hypotheses that post-traumatic reexperimentation is actually an attempt by the nervous system to expose itself to a real event that it could never process (due to emotional intensity), the end of it being (flashbacks, for example) to overcome the pain associated with it.

This mechanism has been used to explain intrusive thinking about food and for the trauma itself, and thus could be a common mechanism.

It is known that people with the comorbidity described have more intense ruminant thoughts, a worse response to drug treatment, a greater tendency towards binge eating, and feelings of guilt of great magnitude existential. PTSD most likely precedes bulimia in time, which is why it is usually considered as 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 this relevant issue, numerous potential mechanisms involved have been described over the years, namely: abusive consumption whose The purpose is to reduce body weight (especially drugs with a stimulant effect, which activate the sympathetic nervous system by altering the process by which store / consume calories), deficits in impulse control (shared with binge eating), and reduced feelings of guilt secondary to the overeating.

Other authors suggest that people with bulimia and substance dependence may be suffering from a dysregulation of the brain's reward system (formed by the nucleus accumbens (NAc), the ventral tegmental area (ATV), and their dopamine projections into the prefrontal cortex), a deep network of structures neurological factors involved in approximation motor responses to appetitive stimuli (and therefore can be "activated" as a result of binge eating and / or use of the drug). That is why bulimia in adolescence is a neurological risk factor for addictions in this period.

In any case, it seems that bulimia precedes the onset 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, thereby weakening 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 as a cause and as a consequence of binge eating (depending on the context).