Bulimia and Addiction: What's the link?

What is bulimia?

Bulimia is a mental health condition – a type of eating disorder – in which a person binges on food, which they then seek to purge or burn off.^[1]

Someone with bulimia will experience periods of excessive eating – known as bingeing – where a large amount of food is consumed in a relatively short space of time (usually less than two hours).

‘Excessive’ is defined as ‘an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances’ ^[1]. It does not, for example, include the large meals most of us eat during holidays such as Thanksgiving.

Someone with bulimia will typically feel a loss of control during these binges, unable to stop themselves from eating, and may feel dissociated or in a daze. They may also feel ashamed of their behavior. For this reason, binge eating often happens in secret or is done discreetly.

To offset bingeing, a person with bulimia will do something to expel or burn off the calories they have consumed. This is commonly referred to as purging and includes vomiting or using laxatives. It can also include excessive exercise.

In some people the condition may be relatively mild, with ‘compensatory behaviors’ such as vomiting or excessive exercise happening perhaps a couple of times a week. For others, it will be extreme and happen more than once a day.^[1]

Is bulimia an addiction?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ^[1] is the manual used by mental health professionals in the USA to diagnose mental health problems. The DSM-5 does not classify bulimia as an addiction. However, there are many similarities between addiction (to, for example, substances such as drugs and alcohol) and bulimia.

The key features of addiction are:^[2]

• A compulsive need – either for a substance or to carry out a particular behavior
• The addictive substance or behavior is harmful in some way
• Stopping or avoiding the substance or behavior brings about symptoms of withdrawal, such as irritability, anxiety and physical symptoms.

For many people with bulimia, they experience these three components. Therefore, they may view their mental health disorder as an addiction.^[3]

Research has also revealed similarities in brain activity for drug addiction and bulimia. Addiction is related to the reward center of the brain; when we take drugs or consume alcohol it affects our brain chemistry which in turn makes us feel pleasure. The same effects have been found in the brains of people when they are bingeing and purging.^[4]

Co-occurrence of bulimia and substance abuse

There appears to be a strong link between bulimia and drug and/or alcohol addiction. According to the DSM-5, about 30% of people with bulimia will also use some kind of substance, especially alcohol and stimulants.^[1]

A 2020 literature review looked at the link between eating disorders and substance misuse. The study found that as many as 70% of people with bulimia may also have a substance use disorder.^[5] It found a particularly strong link between bulimia and alcohol use and indicates that alcohol is often used as an appetite suppressant or as a substitute for food.

In the case of stimulants (such as caffeine, nicotine, and illicit drugs like cocaine), someone with bulimia may be using them as part of efforts to control their body weight.^[1]

Why are bulimia patients more likely to have a substance use disorder?

There are a number of possible explanations for the link between bulimia and substance use disorders.

Similar root causes

Bulimia and substance use disorders share many common causes. The DSMV-5 describes the causes of bulimia, or triggers for bingeing and purging behavior, as follows:^[1]

• Low mood or another mental health problem such as depression or anxiety
• Stress
• Following a restrictive diet
• Poor body image
• Boredom
• Problems in childhood including abuse, bullying due to weight, and early onset of puberty
• Having a family member with bulimia

Many of these are also predictors for substance use disorders. So, for example, it may be that for some people both the development of bulimia and the substance misuse are rooted in depression or abuse in childhood.

Genetics

Various studies have shown that there are genetic links between bulimia and alcohol use disorder. One study found that although bulimia and alcohol use disorder are influenced by different genes, people with both disorders share some common genetic traits. Other studies suggest that people with eating disorders who have a close relative with alcohol use disorder are more likely to drink excessively, which in turn can exacerbate their eating disorder symptoms, rather than cause it. ^[5]

Effects on the brain

Research has shown that the effect drugs and alcohol have on the brain is similar to the effect of bingeing and purging ^[4], which may explain why someone with bulimia is at an increased risk of developing a substance use disorder.

Bulimia can lead to substance use disorder

Some people with bulimia use alcohol or stimulants as a way of suppressing their appetite and controlling their weight ^[1], which may over time lead to addiction, as both alcohol and stimulants carry the potential for dependence after excessive or long-term use.

How does substance abuse affect bulimia patients?

Bulimia can have a number of adverse effects including:^[1]

• Short term problems such as tiredness, dehydration, and injuries (from excessive exercise or vomiting, for example)
• Longer term problems such as osteoporosis, arthritis, and heart problems
• Problems with menstruation, such as an irregular cycle or periods stopping altogether
• An increased risk of suicide

These problems can be exacerbated by abuse of substances such as drugs or alcohol.

In addition, drug and alcohol abuse can result in long term damage to internal organs and increase the risk of heart attacks, strokes, cancer, dementia, and infertility. Abuse of drugs and alcohol can also affect relationships, work or study and cause financial problems.^[6]

Can substance abuse cause bulimia?

There is little evidence to suggest that substance use disorders can directly lead to the development of bulimia nervosa, although the high prevalence of comorbidity suggests that there is a strong link between the two disorders. Studies have shown that substance use disorders, including alcohol use disorder, can make the symptoms of bulimia and other eating disorders worse, although it is not a direct cause. ^[5]

Treatment for bulimia and substance use disorders

The main treatment for bulimia is therapy. Suitable therapies include:^[3][4]

• Cognitive behavioral therapy (CBT), which explores how we think and act and can help us find ways to cope with difficult emotions. There is a particular kind of CBT that has been developed specifically for eating disorders.
• Other therapies such as Interpersonal Therapy (IPT), which can help you address any poor relationships that might be causing or triggering exercise bulimia.
• Family therapy, which can help you and your family understand your condition and how best they can support you.

There is no medication for eating disorders, but you may be prescribed medication to treat an underlying or associated mental health problem, such as an antidepressant.

Talking treatments such as CBT and motivational interviewing (MI) can also be effective for substance use disorders. ^[7] It may be that additional intervention is needed to treat addiction, which may include medication. The Food and Drug Administration has approved medications for the treatment of alcohol and other substance misuse, such as disulfiram, naltrexone, buprenorphine, methadone, and naltrexone. These drugs often work to balance brain chemistry, minimize cravings, or reduce the effects of addictive substances.^[8]