6 most important comorbidities of bulimia nervosa

These are the psychological disorders that frequently overlap with bulimia nervosa.

Eating disorders are undoubtedly a subset of pathologies that have attracted the interest of health professionals and laymen alike. In fact, terms such as "anorexia" or "bulimia" have been extracted from their specialized or technical niche to become part of popular knowledge and consolidated in 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 come to maintain with their own body shape. Other symptoms, such as binge eating or purging, also appear as clear acts of aggression towards one's own body and its functions.

What is really true is that we are dealing with a very severe health problem, which seriously compromises the lives of those who suffer from it and has 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, in particular the co-morbidities 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.

Characteristics of bulimia nervosa

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 preoccupation with food and eating, as well as episodes of overeating (binge eating) that are experienced as a complete loss of control. (binge eating) that are experienced as a complete loss of control. In these moments the individual refers that he/she feels unable to interrupt the behavior, or his/her conscience about the quantities or types of food consumed dissolves. This is why a strong feeling of guilt (which rises above the cervical fear of gaining weight) would also emerge.

In parallel, and in order to stop the emotional discomfort that floods them in these trances, many of them consider putting into practice some compensatory behavior. This can be diverse, ranging from self-induced vomiting to laxative abuse or uncontrolled fasting. The purpose of these strategies is to regulate difficult affects, which the person perceives as overflowing and with which it is very difficult for him/her to cope. In the end, this would provide a relief that would reinforce the cycle of the problem ("eliminate" a difficult emotion), but would unfortunately maintain it over time (in the long term).

Bulimia nervosa, like other eating disorders, has many clinically relevant comorbidities. In fact, it is estimated that 92% of bulimia nervosa it is estimated that 92% of patients will report at least one other mental health problem (although these may be complex combinations). (although these may be complex combinations) at some later point in their lives. This phenomenon would be a major problem, in which a therapeutic plan adapted to the peculiarity of each case would have to be considered (since the enormous variability in the psychopathological expression resulting from its concurrence with other disorders stands out).

Comorbidities of bulimia nervosa: common disorders

The comorbidities that most frequently arise in the context of bulimia nervosa are highlighted below. Of these, the most important are mood, drug use and anxiety.

However, it should be noted that a high percentage also report symptoms of anorexia nervosa throughout their lives, as there is abundant experimental evidence of anorexia nervosa.There is abundant experimental evidence that there are transdiagnostic links between the two (the clinical picture varies 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 a certain erraticism.

According to the current state of the art, the most relevant comorbidities of bulimia nervosa are as follows

1. Depression

Major depression is undoubtedly the most common mental disorder in people suffering from bulimia nervosa.. Its prevalence in life is 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 onset of bulimia, the former being the one that precedes the latter in time, especially when its causes are due to an explicit rejection by the peer group.

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

The negative affect model is one of the most commonly used, and suggests that binge eating in bulimia would be aimed at reducing the psychological distress associated with the mood disorder.The induction of vomiting would aim to minimize the sense of guilt (and anxiety) that results from these episodes of overeating. This is a recurrent cycle that fuels the negative feeling at the base of the problem, facilitating its worsening or the emergence of other comorbidities.

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 lies behind this serious comorbidity. In case 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 in people who report binge eating).

2. Bipolar disorder

Bipolar disorder (type I or II) manifests itself in 10% of bulimia cases, especially in the most severe cases. Symptoms include the recurrent and disabling presence of episodes in which the mood is expansive, irritable and elevated (mania and hypomania), or depressive; together 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, resulting in misdiagnoses that delay the receipt of appropriate help.

When this comorbidity occurs, it is necessary to take into account that treatment with lithium must be supervised more frequently than in other patients, since vomiting and vomiting are more frequent than in other patients.The vomiting can reduce potassium levels and interfere with renal function (promoting a very dangerous increase in drug levels).

As this substance is eliminated by the kidneys, this situation implies an eventually fatal toxicity. It could also happen that the patient refuses its use because of 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 features (such as a tendency to ruminate and impulsivity). It is thought that between 8-33% will refer to 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, the presence of repetitive ideas and an accentuated tendency to self-induced vomiting.

The clinical expression of OCD requires the manifestation of intrusive, difficult to control and recurrent thoughts, 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 the mental contents of weight gain and self-induced vomiting could play the role of obsessions/compulsions in bulimia (respectively), which would resonate in a clear analogy between bulimia and OCD.

Studies on this issue do not suggest an order of presentation for this comorbidity, so that it can start with both OCD and bulimia nervosa. However, in many cases, obsessive-compulsive symptomatology persists despite complete resolution of the eating disorder.

4. Anxiety disorders

Anxiety problems are very common in bulimia nervosa. Panic disorder (11%) is three times more prevalent than in the general population, although this is a difficult relationship to establish.Panic disorder (11%) is three times more prevalent than in the general population, although this relationship is difficult to explain. It tends to be expressed as unpredictable and abrupt episodes of intense physical activation, mediated by the sympathetic nervous system, and presenting with symptoms that are perceived as aversive (tachypnea, sweating, trembling, tachycardia and a feeling 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 may decide to mock or criticize details of their external appearance that they perceive as undesirable.

This comorbidity increases the reluctance to show oneself in public while eating or drinking.This comorbidity increases resistance to showing oneself in public while eating or drinking, as well as fear and apprehensive anticipation of situations in which one might be exposed to judgment, criticism and/or negative evaluations. There is a clear consensus that certain parenting styles (especially those linked to insecure attachments) may precipitate their onset for these patients.

Specific phobias (towards certain stimuli and situations) triple their prevalence (vital) in this disorder (from 10% to 46%), with respect to what is usually estimated for the general population. In this case the phobic stimulus is usually both animal and environmental.Thus, it is attached to the pre-existing aversion (characteristic of such a condition) to weight gain. All specific phobias usually have their origins in a specific experience (aversive in tone), although they are usually maintained through deliberate avoidance mechanisms (negative reinforcement).

Finally, also noteworthy is the high incidence of generalized anxiety disorder, which is expressed as a recurrent preoccupation with a myriad of everyday situations. While it is true that in bulimia nervosa there is often perpetual rumination about eating, 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 purging is resorted to, especially in adolescence, although it occasionally occurs in childhood (up to 75%). It may be that these patients have a more pronounced avoidance tendency.

5. Post-traumatic stress disorder

13% of people with bulimia report the cardinal symptomatological spectrum of post-traumatic stress disorder, a response that the person shows after exposure to a critical or profoundly adverse event.

Specifically, re-experiencing (thoughts/images that reproduce events directly associated with the "trauma"), hyperactivation of the nervous system (constant state of alertness) and avoidance (efforts to flee/escape from the proximity/imminence of stimuli or events linked 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 affect over negative automatic thoughts or threatening images. To such an extent that there are suggestive hypotheses that post-traumatic re-experiencing is in fact an attempt of the nervous system to expose itself to a real event that never happened. an attempt of the nervous system to expose itself to a real event that it was never able to process (because of the emotional intensity), being (because of the emotional intensity), the purpose of which (flashbacks, e.g.) is 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 may be a common mechanism.

It is known that people with the above comorbidity have more intense ruminative thoughts, a worse response to pharmacological treatment, a greater tendency towards binge eating and feelings of guilt of great existential magnitude. PTSD is most likely to precede bulimia in time.It is therefore often considered as a significant risk factor for bulimia.

6. Substance dependence

Substance use is one of the most important problems that occur in people with bipolar disorder.. Numerous potential mechanisms involved have been described in the literature on this relevant issue over the years, namely: abusive consumption aimed at reducing body weight (especially drugs with stimulant effect, which activate the sympathetic nervous system altering the process by which calories are stored/consumed), deficit in impulse control (which is shared with binge eating) and reduction of guilt secondary to overeating.

Other authors suggest that individuals suffering from bulimia and substance dependence may be suffering from dysregulation of the brain's reward system (consisting of 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 approach responses to appetitive stimuli (and which can therefore be "activated" as a result of binge eating and/or drug use). This 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 those of greatest potential risk (for consumption). (for consumption). Finally, other authors have pointed out that the use of a drug would increase impulsivity and reduce inhibition, and thus 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).