Unlike starving, the symptoms of bulimia--primarily binging, purging and laxative use--cause immediate harm to the body. No patient can deny the physical toll these symptoms take. For many, the pain and weariness is a welcome relief from the emotional misery of the eating disorder. Although most patients are terribly afraid of the potential long-term damage, they are just as likely to ignore the risks of their behaviors and signs of deteriorating health. Patients often confuse the immediate physical effects of bulimia with the chronic medical complications and thereby underestimate the serious long term risks. Like with starvation, the body has to adapt to malnutrition and nutrient deficiencies, in this instance from lack of digestion and malabsorption. Unlike anorexia, which the body has an evolutionary inclination to weather, bulimic symptoms are a trauma to endure with a cascade of increasingly toxic effects.
The gastrointestinal system--the part of the body most immediately affected--functions through peristalsis, the muscle contraction initiated by swallowing that pushes food through the system's entire length. Binging, purging and laxatives all disrupt this muscle contraction in quite similar ways. Binging expands the stomach and slows or even stops the muscle contractions temporarily, an effect even more pronounced after purging. Laxatives actively stimulate the colon leading to forceful and often painful diarrhea. These tramuatic shocks to the GI system lead to a period of slowed peristalsis with limited digestion and constipation. After recovery, peristalsis gradually resumes; however, prolonged symptoms can impair the body's ability to return to normal function. For instance, laxatives are addictive and chronic use makes it extremely difficult to have a bowel movement without them. Persistent binging may permanently slow digestion as the stomach is regularly overwhelmed with too much food or expects the contents to be purged. Consistent purging can lead to GI reflux (the food goes backwards into the esophagus) which is experienced as esophageal pain and bleeding.
One lingering effect of bulimic symptoms is electrolyte abnormalities, most notably a low blood potassium level. Purging, laxatives and diuretics all lead to excretion of this essential mineral and a gradual decline in the blood level. Life is considered untenable as the potassium level nears 3.0, but to many doctors' shock and dismay, bulimic patients have been known to walk around with levels under 2.0. For some people, the body adapts to the low level and manages to survive, for a time, but this is the most sudden and lethal complication of bulimia. Low potassium affects the heart rhythm and can precipitate cardiac arrest. Chronic low potassium also leads to kidney damage, and patients with bulimia even end up needing kidney transplants.
These complications are the most destructive, but the list of medical complications is long and equally mind-numbing as that for anorexia: hormonal abnormalities including infertility, slowed cognitive function, breakdown of dental enamel, persistent fluid retention and swelling. Most patients sit quietly waiting for the medical lecture to be over and are too afraid to see the full impact on their bodies. Two factors can help break through the powerful denial and help patients begin to process the risks of their behaviors: fear and timing.
The most common binge trigger is fear: fear of emotions, fear of new situations, fear of people and, ironically, fear of really being hurt by the eating disorder. The last fear is pervasive but hidden deeply beneath the need to binge to survive daily life. Using this fear to chastise the patient drives a wedge into the treatment: no one recovers when being consistently hammered with clinical facts. The therapist needs to broach any discussion of medical complications from a place of genuine compassion and caring. Too often families, friends and, sadly, clinicians place the blame on the patient and undo much of the progress. By trying to understand--and perhaps imagine experiencing--these fears, the therapist can make it safe for the patient to let down her guard. Feeling understood for the first time will allow her to express these feelings and acknowledge her desire to be well and to live fully.
A therapist needs to choose the right time to discuss the medical issues. Even with a sense of safety, a mistimed discussion often becomes an ignored lecture. If a patient is feeling vulnerable and confused but also safe and understood, the medical information can get through and help her face the reality of the eating disorder. This component of therapy relies heavily on the therapeutic relationship and on the therapist's ability to surmise that the patient is ready to trust the treatment enough to face her reality.
These two posts highlight how damaging and even lethal eating disorders are. Patients and therapists are often afraid to discuss these consequences and risk overwhelming the treatment. At the same time, any therapist who avoids this discussion is remiss. Engaging in this part of eating disorder treatment successfully sidesteps the patient's most valued protector, denial, and opens the door for another deeper question. How do you maintain hope during treatment for an eating disorder? Look for the next post.