Bulimia Nervosa

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Bulimia nervosa is an eating disorder characterized by binge eating and engaging in inappropriate ways of counteracting the bingeing (using laxatives, for example) to prevent weight gain. The word “bulimia” is the Latin form of the Greek word boulimia, which means “extreme hunger.” A binge is consuming a larger amount of food within a limited period of time than most people would eat in similar circumstances. Most people with bulimia report feelings of loss of control associated with bingeing, and some have mildly dissociative experiences in the course of a binge, which means that they feel disconnected from themselves and from reality when they binge.

The handbook for mental health professionals to aid in diagnosis is the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-IVTR. It categorizes bulimia nervosa as an eating disorder, along with anorexia nervosa.

Description

Bulimia nervosa is classified into two subtypes according to the methods used by the patient to prevent weight gain after a binge. The purging subtype of bulimia is characterized by the use of self-induced vomiting, laxatives, enemas, or diuretics (pills that induce urination); in the nonpurging subtype, fasting or overexercising is used to compensate for binge eating.

The onset of bulimia nervosa is most common in late adolescence or early adult life. Dieting efforts and body dissatisfaction, however, often occur in the teenage years. For these reasons, it is often described as a developmental disorder. Genetic researchers have identified specific genes linked to susceptibility to eating disorders, and the environmental primary factor in the development of bulimia nervosa is stress related to the onset of puberty. Girls who have strongly negative feelings about their bodies in response to puberty are at high risk for developing bulimia.

The binge eating associated with bulimia begins most often after a period of strict dieting. Most people with bulimia develop purging behaviors in response to the bingeing. Vomiting is used by 80-90% of patients diagnosed with bulimia. The personal accounts of recovered bulimics suggest that most “discover” vomiting independently as a way of ridding themselves of the food rather than learning about it from other adolescents. Vomiting is often done to relieve an uncomfortable sensation of fullness in the stomach following a binge as well as to prevent absorption of the calories in the food. Vomiting is frequently induced by touching the gag reflex at the back of the throat with the fingers or a toothbrush, but a minority of patients use syrup of ipecac to induce vomiting. About one-third of bulimics use laxatives after binge eating to empty the digestive tract, and a minority use diuretics or enemas. Purging behaviors lead to a series of digestive and metabolic disturbances that then reinforce the behaviors.

A small proportion of bulimics exercise excessively or fast after a binge instead of purging.

Patients with bulimia may come to the attention of a psychiatrist because they develop medical or dental complications of the eating disorder. In some cases, the adolescent’s dentist is the “case finder.” In many cases, however, the person with bulimia seeks help.

Causes and symptoms

Causes

Bulimia nervosa is understood to be a complex disorder with multiple factors contributing to its development. Studies suggest an interaction among genetics, familial factors, and social pressures in the development of an eating disorder.

GENETICS

Several studies have obtained results pointing to a genetic understructure for eating disorders, including bulimia. Studies investigating the relationship between characteristics of bulimia in families and their correlation with patterns of gene expression have linked bulimia to genes on human chromosome 10.

FAMILIAL FACTORS

A number of recent studies point to the interpersonal relationships in the family of origin (the patient’s family while growing up) as a factor in the later development of bulimia. People with bulimia are more likely than people with anorexia to have been sexually abused in childhood; studies have found that abnormalities in blood levels of serotonin (a neurotransmitter associated with mood disorders) and cortisol (the primary stress hormone in humans) in bulimic patients with a history of childhood sexual abuse resemble those in patients with post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is a mental disorder that can develop after someone has experienced a traumatic event (horrors of war, for example) and is unable to put that event behind him or her—the disorder is characterized by very realistic flashbacks of the traumatic event.

A history of eating conflicts and struggles over food in the family of origin is also a risk factor for the development of bulimia nervosa. Personal accounts by recovered bulimics frequently note that one or both parents were preoccupied with food or dieting. Fathers appear to be as influential as mothers in this regard. A recent study focusing on girls suggests that the influence of the father may be related to the father’s own concerns and body preoccupations and that this influence may be stronger as a child gets older. Other risk factors identified in a 2007 study, which followed the children from birth, were a low activity level in early childhood and rapid eating in later childhood. In addition, and not surprisingly, peer and parental teasing about body weight or shape also increase risk.

An additional risk factor for early-onset bulimia is interest in or preparation for a sport or occupation that requires strict weight control, such as gymnastics, figure skating, horse jockeying, wrestling, or modeling.

SOCIOCULTURAL CAUSES

Emphasis in the mass media on slenderness in women as the primary criterion of beauty and desirability is commonly noted in studies of bulimia. Historians of fashion have remarked that the standard of female attractiveness has changed over the past half century in the direction of greater slenderness; some have commented that Marilyn Monroe would be considered “fat” by contemporary standards. The ideal female figure is not only unattainable by the vast majority of women, but is lighter than the standards associated with good health by insurance companies. In 1965 the average model weighed 8% less than the average American woman; by 2001, she weighed 25% less. Recent news reports have focused on this obsession with thinness in the fashion industry because of the deaths of several models from eating disorders. One major fashion group in Spain went so far as to set a minimum body mass index for models on its catwalks in 2006 after a model died during a show in South America of causes apparently related to an eating disorder. In the United States, magazine covers feature razor-thin actresses with alarmed questions about their weight and health splashed across the covers, sending a mixed message.

Another factor mentioned by intellectual historians is the centuries-old split in Western philosophy between mind and body. Instead of regarding a human person as a unified whole consisting of body, soul, and mind, Western thought since Plato has tended to divide human nature in a dualistic fashion between the life of the mind and the needs of the body. Furthermore, this division was associated with gender symbolism in such a way that the life of the mind was associated with masculinity and the needs of the body with femininity. The physical dimension of human life was correlated with men’s physical, legal, and economic domination of women. Although this dualistic pattern of symbolic thought is no longer a conscious part of the Western mindset, it appears to influence Western culture on a subconscious level.

A number of different theories have been put forward to explain the connections between familial and social factors and bulimia. Some of these theories include:

• Bulimia results from a conflict between mother and daughter about nurturing and dependency. Girls are typically weaned earlier than boys and fed less. The bulimic’s bingeing and purging represent a conflict between wanting comfort and believing that she does not deserve it.

• Bulimia develops when an adolescent displaces larger conflicts about being a woman in a hypersexualized society onto food. Many writers have commented about the contradictory demands placed on women in contemporary society—for example, to be sexually appealing yet “untouchable” at the same time. Controlling body size and food intake becomes a simplified solution to a very complex problem of personal identity and moral standards.
• Bulimia is an obsession with food that the culture encourages to protect men from competition from intellectually liberated women. Women who are spending hours each day thinking about food, or bingeing and purging, do not have the emotional and intellectual energy to take their rightful places in the learned professions and the business world.
• Bulimia expresses a fear of fat rooted in childhood memories of mother’s size relative to one’s own.
• Bulimia results from intensified competition among women for professional achievement (getting a desirable job or a promotion, or being accepted into graduate or professional school) as well as personal success (getting a husband), because studies have indicated that businesses and graduate programs discriminate against overweight applicants.
• Bulimia results from attempts to control emotional chaos in one’s interpersonal relationships by imposing rigid controls on food intake.

Nutrition experts have pointed to the easy availability of foods high in processed carbohydrates in developed countries as a social factor that contributes to the incidence of bulimia. One study found that subjects who were given two slices of standard mass-produced white bread with some jelly had their levels of serotonin increased temporarily by 450%. This finding suggests that bulimics who binge on ice cream, bread, cookies, pizza, and fast food items that are high in processed carbohydrates are simply manipulating their neurochemistry in a highly efficient manner. The incidence of bulimia may be lower in developing countries because diets that are high in vegetables and whole-grain products but low in processed carbohydrates do not affect serotonin levels in the brain as rapidly or as effectively.

Symptoms

The DSM-IV-TR specifies that bingeing and the inappropriate attempts to compensate for it must occur twice a week for three months on average to meet the diagnostic criteria for bulimia nervosa.

A second criterion of bulimia nervosa is exaggerated concern with body shape and weight. Bulimia can be distinguished from body dysmorphic disorder (BDD) by the fact that people with BDD usually focus on a specific physical feature—most commonly a facial feature—rather than overall shape and weight. Bulimics do, however, resemble patients with BDD in that they have distorted body images.

Bulimia is associated with a number of physical symptoms. Binge eating by itself rarely causes serious medical complications, but it is associated with nausea, abdominal distension and cramping, slowed digestion, and weight gain.

Self-induced vomiting, on the other hand, may have serious medical consequences, including:

• Erosion of tooth enamel, particularly on the molars and maxillary incisors. Loss of tooth enamel is irreversible.
• Enlargement of the salivary glands.
• Scars and calloused areas on the knuckles from contact with the teeth.
• Irritation of the throat and esophagus from contact with stomach acid.
• Tearing of mucous membranes in the upper gastrointestinal tract or perforation of the esophagus and stomach wall. Perforation of part of the digestive tract is a rare complication of bulimia but is potentially fatal.
• Electrolyte imbalances. The loss of fluids from repeated vomiting and laxative abuse can deplete the body’s stores of hydrogen chloride, potassium, sodium, and magnesium. Hypokalemia (abnormally low levels of potassium in the blood) is a potential medical emergency that can lead to muscle cramps, seizures, and heart arrhythmias.

Other physical symptoms associated with bulimia include irregular menstrual periods or amenorrhea; petechiae (pinhead-sized bruises from capillaries ruptured by increased pressure due to vomiting) in the skin around the eyes, and rectal prolapse (the lowering of the rectum from its usual position).

Demographics

Bulimia nervosa affects between 1% and 3% of women in the developed countries; its prevalence is thought to have increased markedly since 1970. The rates are similar across cultures as otherwise different as the United States, Japan, the United Kingdom, Australia, South Africa, Canada, France, Germany, and Israel. About 80% to 90% of patients with bulimia are female.

The average age at onset of bulimia nervosa appears to be dropping in the developed countries. A study of eating disorders in Rochester, Minnesota, over the 50 years between 1935 and 1985 indicated that the incidence rates for women over 20 remained fairly constant, but there was a significant rise for women between 15 and 20 years of age. The average age at onset among women with bulimia was 14 and among men, 18.

Homosexual men appear to be as vulnerable to developing bulimia as heterosexual women, while lesbians are less vulnerable.

Recent studies indicate that bulimia in the United States is no longer primarily a disorder of Caucasian women; the rates among African American and Hispanic women have risen faster than the rate of bulimia for the female population as a whole. One report indicates that the chief difference between African American and Caucasian bulimics in the United States is that the African American patients are less likely to eat restricted diets between episodes of binge eating.

Diagnosis

The diagnosis of bulimia nervosa is made on the basis of a physical examination, a psychiatric assessment, the patient’s eating history, and the findings of laboratory studies. Patients who do not meet the full criteria for bulimia nervosa may be given the diagnosis of subsyndromal bulimia or of an eating disorder not otherwise specified (EDNOS).

Physical examination

Patients suspected of having bulimia nervosa should be given a complete physical examination because the disorder has so many potential medical complications. In addition, most bulimics are close to normal weight or only slightly overweight, and so do not look outwardly different from most people of their sex in their age group. The examination should include not only vital signs and an assessment of the patient’s height and weight relative to age, but also checking for such signs of bulimia as general hair loss, abdominal soreness, swelling of the parotid glands, telltale scars on the back of the hand, petechiae, edema, and teeth that look ragged or “moth-eaten.”

Psychiatric assessment

Psychiatric assessment of patients with bulimia usually includes four components:

• a thorough history of body weight, eating patterns, diets, typical daily food intake, methods of purging (if used), and concept of ideal weight.
• a history of the patient’s significant relationships with parents, siblings, and peers, including present or past physical, emotional, or sexual abuse.
• a history of previous psychiatric treatment (if any) and assessment of comorbid (occurring at the same time as the bulimia) mood, anxiety, substance abuse, or personality disorders.
• administration of standardized instruments that measure attitudes toward eating, body size, and weight. Common tests for eating disorders include the Eating Disorder Examination; the Eating Disorder Inventory; the Eating Attitude Test, or EAT; and the Kids’ Eating Disorder Survey (KEDS).

Laboratory findings

Laboratory tests ordered for patients suspected of having bulimia usually include a complete blood cell count, blood serum chemistry, thyroid tests, and urinalysis. If necessary, the doctor may also order a chest x ray and an electrocardiogram (EKG). Typical findings in patients with bulimia include low levels of chloride and potassium in the blood, and higher than normal levels of amylase, a digestive enzyme found in saliva.

Treatments

Treatment for bulimia nervosa typically involves several therapy approaches. It is, however, complicated by several factors.

First, patients diagnosed with bulimia nervosa frequently have coexisting psychiatric disorders that typically include major depression, dysthymic disorder, anxiety disorders, substance abuse disorders, or personality disorders. In the case of depression, the mood disorder may either precede or follow the onset of bulimia, and, with bulimia, the prevalence of depression is 40-70%. With regard to substance abuse, about 30% of patients diagnosed with bulimia nervosa abuse either alcohol or stimulants over the course of the eating disorder. The personality disorders most often diagnosed in bulimics are the so-called Cluster B disorders—borderline, narcissistic, histrionic, and antisocial. Borderline personality disorder is a disorder characterized by stormy interpersonal relationships, unstable self-image, and impulsive behavior. People with narcissistic personality disorder believe that they are extremely important and are unable to have empathy for others. Individuals with histrionic personality disorder seek attention almost constantly and are very emotional. Antisocial personality disorder is characterized by a behavior pattern of a disregard for others’ rights—people with this disorder often deceive and manipulate others. Although patients may have both bulimia nervosa and anorexia nervosa, a number of clinicians have noted that patients with predominate bulimia tend to develop impulsive and unstable personality disturbances whereas patients with predominate anorexia tend to be more obsessional and perfectionistic. Estimates of the prevalence of personality disorders among patients with bulimia range between 2% and 50%. The clinician must then decide whether to treat the eating disorder and the comorbid conditions concurrently or sequentially. It is generally agreed, however, that a substance abuse disorder, if present, must be treated before the bulimia can be effectively managed. It is also generally agreed that mood disorders and bulimia can be treated concurrently, often using antidepressant medication along with therapy.

Second, the limitations on treatment imposed by managed care complicate the treatment of bulimia nervosa. When the disorder first received attention in the 1970s, patients with bulimia were often hospitalized until the most significant physical symptoms of the disorder could be treated. Few patients with bulimia are hospitalized today, however, with the exception of medical emergencies related to electrolyte imbalances and gastrointestinal injuries associated with the eating disorder. Most treatment protocols for bulimia nervosa now reflect cost-containment measures.

Medications

The most common medications given to patients are antidepressants, because bulimia is so closely associated with depression. Short-term medication trials have reported that tricyclic antidepressants—desipramine, imipramine, and amitriptyline—reduce episodes of binge eating by 47-91% and vomiting by 45-78%. The monoamine oxidase inhibitors are not recommended as initial medications for patients diagnosed with bulimia because of their side effects. The most promising results have been obtained with the selective serotonin reuptake inhibitors, or SSRIs. Fluoxetine (Prozac) was approved in 1998 by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa. Effective dosages of fluoxetine are higher for the treatment of bulimia than they are for the treatment of depression. Although a combination of medication and cognitive-behavioral therapy is more effective in treating most patients with bulimia than medication alone, one team of researchers reported success in treating some bulimics who had not responded to psychotherapy with fluoxetine by itself.

Ondansetron (Zofran), a drug that was originally developed to control nausea from chemotherapy and radiation therapy for cancer, blocks serotonin reuptake and also works to inhibit vomiting. It has shown some benefit in ameliorating symptoms of bulimia nervosa.

In addition to antidepressant or antinausea medications, such acid-reducing medications as cimetidine and ranitidine, or antacids, may be given to patients with bulimia to relieve discomfort in the digestive tract associated with irritation caused by stomach acid.

Psychotherapy

Cognitive-behavioral therapy (CBT) is regarded as the most successful psychotherapeutic approach to bulimia nervosa. CBT is intended to interrupt the faulty thinking processes associated with bulimia, such as preoccupations with food and weight, black-white thinking (“all or nothing” thinking, or thinking thoughts only at extreme ends of a spectrum), and low self-esteem, as well as such behaviors as the binge-purge cycle. Patients are first helped to regain control over their food intake by keeping food diaries and receiving feedback about their meal plans, symptom triggers, nutritional balance, and so on. They are then taught to challenge rigid thought patterns by receiving assertiveness training and practice in identifying and expressing their feelings in words rather than through distorted eating patterns. About 50% of bulimic patients treated with CBT are able to stop bingeing and purging. Of the remaining half, some show partial improvement and a small minority do not respond at all.

Family therapy is sometimes recommended as an additional mode of treatment for patients with bulimia who come from severely troubled or food-obsessed families that increase their risk of relapsing.

Other mainstream therapies

Medical nutrition therapy, or MNT, is a recognized component of the treatment of eating disorders. Effective MNT for patients with bulimia involves an understanding of cognitive-behavioral therapy as well as the registered dietitian’s usual role of assisting the physician with monitoring the patient’s physical symptoms, laboratory values, and vital signs. In the treatment of bulimia, the dietitian’s specialized knowledge of nutrition may be quite helpful in dealing with the myths about food and fad diets that many bulimic patients believe. The dietitian’s most important task, however, is helping the patient to normalize her or his eating patterns to break the deprivation/bingeing cycle that is characteristic of bulimia nervosa. Calorie intake is usually based on retaining the patient’s weight to prevent hunger, because hunger increases susceptibility to bingeing.

KEY TERMS

Binge —An excessive amount of food consumed in a short period of time. Usually, while a person binge eats, he or she feels disconnected from reality, and feels unable to stop. The bingeing may temporarily relieve depression or anxiety, but after the binge, the person usually feels guilty and depressed.

Body image —A term that refers to a person’s inner picture of his or her outward appearance. It has two components: perceptions of the appearance of one’s body, and emotional responses to those perceptions.

Comorbidity —Association or presence of two or more mental disorders in the same patient. A disorder that is said to have a high degree of comorbidity is likely to occur in patients diagnosed with other disorders that may share or reinforce some of its symptoms.

Cortisol —A steroid hormone released by the cortex (outer portion) of the adrenal gland when a person is under stress.

Diuretic —A medication or substance given to increase the amount of urine excreted.

Dysthymic disorder —A mood disorder that is less severe than depression but usually more chronic.

Electrolytes —Substances or elements that dissociate into electrically charged particles (ions) when dissolved in the blood. The electrolytes in human blood include potassium, magnesium, and chloride.

Hypokalemia —Abnormally low levels of potassium in the blood. Hypokalemia is a potential medical emergency, as it can lead to disturbances in of the heart rhythm. Muscle cramps and pain are a common symptom of hypokalemia in bulimic patients.

Incisors —The four teeth in the front of each jaw in humans. The incisors of patients with bulimia frequently show signs of erosion from stomach acid.

Ipecac —The dried root of Caephalis ipecacuanha, a South American plant. Given in syrup form, ipecac is most commonly used to induce vomiting in cases of accidental poisoning.

Petechiae —Pinpoint-sized hemorrhages in the skin or a mucous membrane. In bulimia, petechiae may appear in the skin around the eyes as a result of increased pressure in the capillaries caused by vomiting.

Purging —Inappropriate actions taken to prevent weight gain, often after bingeing, including self-induced vomiting or the misuse of laxatives, diuretics, enemas, or other medications.

Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.

One study from upstate New York found that bright light therapy (regular exposure to ultraviolet light), of the type frequently prescribed for seasonal affective disorder (SAD), appears to be effective in reducing binge eating in patients diagnosed with bulimia. It also significantly relieved depressive symptoms, as measured by the patients’ scores on the Beck Depression Inventory. As of 2007, no further studies addressing the effect of bright light on binge eating have been published.

Alternative and complementary treatments

Alternative therapies that have been shown to be helpful for some patients in relieving the anxiety and muscular soreness associated with bulimia nervosa include acupuncture, massage therapy, hydrotherapy, and shiatsu.

Herbal remedies that have been used to calm digestive upsets in bulimic patients include teas made from chamomile or peppermint. Peppermint helps to soothe the intestines by slowing down the rate of smooth muscle contractions (peristalsis). Chamomile has been used to help expel gas from the digestive tract, a common complaint of bulimics. Both herbs have a wide margin of safety.

Some bulimic patients have responded well to yoga because its emphasis on focused breathing and meditation calls attention to and challenges the distorted thought patterns that characterize bulimia. In addition, the stretching and bending movements that are part of a yoga practice help to displace negative thoughts focused on the body’s outward appearance with positive appreciation of its strength and agility. Last, because yoga is noncompetitive, it allows bulimics to explore the uniqueness of their bodies rather than constantly comparing themselves to other people.

Prognosis

The prognosis of bulimia depends on several factors, including age at onset, types of purging behaviors used (if any), and the presence of other psychiatric conditions or disorders. In many cases, the disorder becomes a chronic (long-term) condition; 20-50% of patients have symptoms for at least five years in spite of treatment. The usual pattern is an alternation between periods of remission and new episodes of bingeing. Patients whose periods of remission last for a year or longer have a better prognosis; patients diagnosed with major depression or a personality disorder have a less favorable prognosis. Overall, however, the prognosis for full recovery from bulimia nervosa is considered relatively poor compared to other eating disorders.

Bulimia nervosa appears to produce changes in the functioning of the serotonin system in the brain. A team of researchers at the University of Pittsburgh who compared brain images taken by positron emission tomography (PET) from bulimic women who had been in remission for a year or longer with brain images from healthy women found that the recovered bulimics did not have a normal age-related decline in serotonin binding. Because serotonin helps to regulate mood, appetite, and impulse control, the study may help to explain why some women may be more susceptible to developing bulimia than others.

Prevention

Although a genetic link to bulimia has been identified, there are currently no gene-based preventive measures. With regard to family influences, the overwhelming majority of studies have found that the most important preventive measure that can be taken is the establishment of healthful eating patterns and attitudes toward food in the family of origin.

See alsoNutrition counseling.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

“Bulimia Nervosa.” Section 15, Chapter 196. The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Chernin, Kim. The Obsession: Reflections on the Tyranny of Slenderness. Revised edition. New York: HarperPerennial Editions, 1994.

Eichenbaum, Luise, and Susie Orbach. Understanding Women: A Feminist Psychoanalytic Approach. New York: Basic Books, Publishers, 1983.

Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: HarperPerennial Editions, 1999.

Newmark, Gretchen Rose. “Overcoming Eating Disorders.” In Living Yoga: A Comprehensive Guide for Daily Life, edited by Georg Feuerstein and Stephan Bodia. New York: Jeremy P. Tarcher/Perigee, 1993.

Rodin, Judith, PhD. Body Traps: Breaking the Binds That Keep You from Feeling Good About Your Body. New York: William Morrow, 1992.

Roth, Geneen. When Food is Love. New York: Penguin Books, 1992.

Wolf, Naomi. The Beauty Myth: How Images of Beauty Are Used Against Women. New York: Anchor Books, 1992.

PERIODICALS

Agras, Stewart W., and others. “Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to be Thin.” Journal of the American Academy of Child and Adolescent Psychiatry 46 (2007): 171–78.

Bulik, Cynthia M. “Exploring the Gene-Environment Nexus in Eating Disorders.” Journal of Psychiatry and Neuroscience 30 (2005): 335–39.

Bulik, C. M., and others. “Twin Studies of Eating Disorders: A Review.” International Journal of Eating Disorders 27 (2000): 1–20.

Eliot, A. W., and C. W. Baker. “Eating Disordered Adolescent Males.” Adolescence 36 (Fall 2001): 535–43.

Fairburn, Christopher C. “The Natural Course of Bulimia Nervosa and Binge Eating Disorder in Young Women.” Journal of the American Medical Association 284 (October 18, 2000): 1906.

Hay, Phillipa J., and Josué Bacaltchuk. “Bulimia Nervosa: Review of Treatments.” British Medical Journal 303 (July 7, 2001): 33–37.

Kaye, Walter H., Guido K. Frank, Carolyn C. Meltzer, and others. “Altered Serotonin 2A Receptor Activity in Women Who Have Recovered from Bulimia Nervosa.” American Journal of Psychiatry 158 (July 2001): 1152–55.

Kotler, Lisa A., Patricia Cohen, Mark Davies, and others. “Longitudinal Relationships Between Childhood, Adolescent, and Adult Eating Disorders.” Journal of the American Academy of Child and Adolescent Psychiatry 40 (December 2001): 1434–40.

“Light Therapy for Bulimia.” Family Practice News 10 (February 1, 2000): 32.

Little, J. W. “Eating Disorders: Dental Implications.” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 93 (February 2002): 138–43.

McGilley, Beth M., and Tamara L. Pryor. “Assessment and Treatment of Bulimia Nervosa.” American Family Physician 57 (June 1998): 1339.

Miller, Karl E. “Cognitive Behavior Treatment of Bulimia Nervosa.” American Family Physician 63 (February 1, 2001): 536.

“Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified.” Journal of the American Dietetic Association 101 (July 2001): 810–28.

Romano, Steven J., Katherine A. Halmi, Neena P. Sankar, and others. “A Placebo-Controlled Study of Fluoxetine in Continued Treatment of Bulimia Nervosa After Successful Acute Fluoxetine Treatment.” American Journal of Psychiatry 159 (January 2002): 96-102.

Steiger, Howard, Lise Gauvin, Mimi Israel, and others. “Association of Serotonin and Cortisol Indices with Childhood Abuse in Bulimia Nervosa.” Archives of General Psychiatry 58 (September 2001): 837.

Vink, T., A. Hinney, A. A. van Elburg, and others. “Association Between an Agouti-Related Protein Gene Polymorphism and Anorexia Nervosa.” Molecular Psychiatry 6 (May 2001): 325–28.

Walling, Anne D. “Anti-Nausea Drug Promising in Treatment of Bulimia Nervosa.” American Family Physician 62 (September 1, 2000): 1156.

ORGANIZATIONS

Academy for Eating Disorders, Montefiore Medical School, Adolescent Medicine. 111 East 210th Street, Bronx, NY 10467. Telephone: (718) 920-6782.

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue N.W., Washington, DC 20016-3007. Telephone: (202) 966-7300. Fax: (202) 966-2891. <http://www.aacap.org>.

American Anorexia/Bulimia Association. 165 W. 46th Street, Suite 1108, New York, NY 10036. Telephone: (212) 575-6200.

American Dietetic Association. Telephone: (800) 877-1600. <http://www.eatright.org>.

Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED). P.O. Box 5102, Eugene, OR 97405. Telephone: (541) 344-1144. <http://www.anred.com>.

Center for the Study of Anorexia and Bulimia. 1 W. 91st St., New York, NY 10024. Telephone: (212) 595-3449.

OTHER

“Bulima Nervosa.” U.S. Department of Health and Human Services. <http://www.womenshealth.gov/faq/Easy-read/bulnervosa-etr.htm>.

Rebecca Frey, PhD
Emily Jane Willingham, PhD

Bulimia nervosa

Definition

Bulimia nervosa is an eating disorder characterized by binge eating and engaging in inappropriate ways of counteracting the bingeing (using laxatives, for example) in order to prevent weight gain. The word "bulimia" is the Latin form of the Greek word boulimia, which means "extreme hunger." A binge is consuming a larger amount of food within a limited period of time than most people would eat in similar circumstances. Most people with bulimia report feelings of loss of control associated with bingeing, and some have mildly dissociative experiences in the course of a binge, which means that they feel disconnected from themselves and from reality when they binge.

The handbook for mental health professionals to aid in diagnosis is the Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM-IV-TR. This book categorizes bulimia nervosa as an eating disorder, along with anorexia nervosa .

Description

Bulimia nervosa is classified into two subtypes according to the methods used by the patient to prevent weight gain after a binge. The purging subtype of bulimia is characterized by the use of self-induced vomiting, laxatives, enemas, or diuretics (pills that induce urination); in the nonpurging subtype, fasting or overexercising is used to compensate for binge eating.

The onset of bulimia nervosa is most common in late adolescence or early adult life. Dieting efforts and body dissatisfaction, however, often occur in the teenage years. For these reasons, it is often described as a developmental disorder. Although genetic researchers have identified specific genes linked to susceptibility to eating disorders, the primary factor in the development of bulimia nervosa is environmental stress related to the onset of puberty. Girls who have strongly negative feelings about their bodies in response to puberty are at high risk for developing bulimia.

The binge eating associated with bulimia begins most often after a period of strict dieting. Most people with bulimia develop purging behaviors in response to the bingeing. Vomiting is used by 80%–90% of patients diagnosed with bulimia. The personal accounts of recovered bulimics suggest that most "discover" vomiting independently as a way of ridding themselves of the food rather than learning about it from other adolescents. Vomiting is often done to relieve an uncomfortable sensation of fullness in the stomach following a binge as well as to prevent absorption of the calories in the food. Vomiting is frequently induced by touching the gag reflex at the back of the throat with the fingers or a toothbrush, but a minority of patients use syrup of ipecac to induce vomiting. About a third of bulimics use laxatives after binge eating to empty the digestive tract, and a minority use diuretics or enemas. Purging behaviors lead to a series of digestive and metabolic disturbances that then reinforce the behaviors.

A small proportion of bulimics exercise excessively or fast after a binge instead of purging.

Patients with bulimia may come to the attention of a psychiatrist because they develop medical or dental complications of the eating disorder. In some cases, the adolescent's dentist is the "case finder." In many cases, however, the person with bulimia seeks help.

Causes and symptoms

Causes

As of 2002, bulimia nervosa is understood to be a complex disorder with multiple factors contributing to its development. Researchers presently disagree about the degree of influence exerted by genetic factors, psychological patterns in the family of origin, and social trends.

GENETIC. Two recently published reviews (in 1999 and 2000) suggest that there is some heritability for bulimia. In other words, these articles suggest that there is a genetic component to bulimia. Neurotransmitters are chemicals that pass chemical messages along from nerve cell to nerve cell, and people with bulimia have abnormal levels of certain neurotransmitters. Some observers have suggested that these abnormalities in the levels of central nervous system neurotransmitters may also be influenced by genetic factors.

FAMILY OF ORIGIN. A number of recent studies point to the interpersonal relationships in the family of origin (the patient's family while growing up) as a factor in the later development of bulimia. People with bulimia are more likely than people with anorexia to have been sexually abused in childhood; studies have found that abnormalities in blood levels of serotonin (a neurotransmitter associated with mood disorders) and cortisol (the primary stress hormone in humans) in bulimic patients with a history of childhood sexual abuse resemble those in patients with post-traumatic stress disorder . Post-traumatic stress disorder is a mental disorder that can develop after someone has experienced a traumatic event (horrors of war, for example) and is unable to put that event behind him or her— the disorder is characterized by very realistic flashbacks of the traumatic event.

A history of eating conflicts and struggles over food in the family of origin is also a risk factor for the development of bulimia nervosa. Personal accounts by recovered bulimics frequently note that one or both parents were preoccupied with food or dieting. Fathers appear to be as influential as mothers in this regard.

An additional risk factor for early-onset bulimia is interest in or preparation for a sport or occupation that requires strict weight control, such as gymnastics, figure skating, ballet, and modeling.

SOCIOCULTURAL CAUSES. Emphasis in the mass media on slenderness in women as the primary criterion of beauty and desirability is commonly noted in studies of bulimia. Historians of fashion have remarked that the standard of female attractiveness has changed over the past half century in the direction of greater slenderness; some have commented that Marilyn Monroe would be considered "fat" by contemporary standards. The ideal female figure is not only unattainable by the vast majority of women, but is lighter than the standards associated with good health by insurance companies. In 1965 the average model weighed 8% less than the average American woman; as of 2001 she weighs 25% less.

Another factor mentioned by intellectual historians is the centuries-old split in Western philosophy between mind and body. Instead of regarding a human person as a unified whole comprised of body, soul, and mind, Western thought since Plato has tended to divide human nature in a dualistic fashion between the life of the mind and the needs of the body. Furthermore, this division was associated with gender symbolism in such a way that the life of the mind was associated with masculinity and the needs of the body with femininity. The notion that the "superior" mind should control the "inferior" physical dimension of human life was correlated with men's physical, legal, and economic domination of women. Although this dualistic pattern of symbolic thought is no longer a conscious part of the Western mindset, it appears to influence Western culture on a subterranean level.

A number of different theories have been put forward to explain the connections between familial and social factors and bulimia. Some of these theories maintain that:

• Bulimia results from a conflict between mother and daughter about nurturing and dependency. Girls are typically weaned earlier than boys and fed less. The bulimic's bingeing and purging represent a conflict between wanting comfort and believing that she does not deserve it.
• Bulimia develops when an adolescent displaces larger conflicts about being a woman in a hypersexualized society onto food. Many writers have commented about the contradictory demands placed on women in contemporary society— for example, to be sexually appealing yet "untouchable" at the same time. Controlling body size and food intake becomes a simplified solution to a very complex problem of personal identity and moral standards.
• Bulimia is an obsession with food that the culture encourages in order to protect men from competition from intellectually liberated women. Women who are spending hours each day thinking about food, or bingeing and purging, do not have the emotional and intellectual energy to take their places in the learned professions and the business world.
• Bulimia expresses a fear of fat rooted in childhood memories of mother's size relative to one's own.
• Bulimia results from intensified competition among women for professional achievement (getting a desirable job or a promotion, or being accepted into graduate or professional school) as well as personal success (getting a husband), because studies have indicated that businesses and graduate programs discriminate against overweight applicants.
• Bulimia results from attempts to control emotional chaos in one's interpersonal relationships by imposing rigid controls on food intake.

Nutrition experts have pointed to the easy availability of foods high in processed carbohydrates in developed countries as a social factor that contributes to the incidence of bulimia. One study found that subjects who were given two slices of standard mass-produced white bread with some jelly had their levels of serotonin increased temporarily by 450%. This finding suggests that bulimics who binge on ice cream, bread, cookies, pizza, and fast food items that are high in processed carbohydrates are simply manipulating their neurochemistry in a highly efficient manner. The incidence of bulimia may be lower in developing countries because diets that are high in vegetables and whole-grain products but low in processed carbohydrates do not affect serotonin levels in the brain as rapidly or as effectively.

Symptoms

The DSM-IV-TR specifies that bingeing and the inappropriate attempts to compensate for it must occur twice a week for three months on average to meet the diagnostic criteria for bulimia nervosa.

A second criterion of bulimia nervosa is exaggerated concern with body shape and weight. Bulimia can be distinguished from body dysmorphic disorder (BDD) by the fact that people with BDD usually focus on a specific physical feature— most commonly a facial feature— rather than overall shape and weight. Bulimics do, however, resemble patients with BDD in that they have distorted body images.

Bulimia is associated with a number of physical symptoms. Binge eating by itself rarely causes serious medical complications, but it is associated with nausea, abdominal distension and cramping, slowed digestion, and weight gain.

Self-induced vomiting, on the other hand, may have serious medical consequences, including:

• Erosion of tooth enamel, particularly on the molars and maxillary incisors. Loss of tooth enamel is irreversible.
• Enlargement of the salivary glands.
• Scars and calloused areas on the knuckles from contact with the teeth.
• Irritation of the throat and esophagus from contact with stomach acid.
• Tearing of mucous membranes in the upper gastrointenstinal tract or perforation of the esophagus and stomach wall. Perforation of part of the digestive tract is a rare complication of bulimia but is potentially fatal.
• Electrolyte imbalances. The loss of fluids from repeated vomiting and laxative abuse can deplete the body's stores of hydrogen chloride, potassium, sodium, and magnesium. Hypokalemia (abnormally low levels of potassium in the blood) is a potential medical emergency that can lead to muscle cramps, seizures , and heart arrhythmias.

Other physical symptoms associated with bulimia include irregular menstrual periods or amenorrhea; petechiae (pinhead-sized bruises from capillaries ruptured by increased pressure due to vomiting) in the skin around the eyes and rectal prolapse (the lowering of the rectum from its usual position).

Demographics

Bulimia nervosa affects between 1% and 3% of women in the developed countries; its prevalence is thought to have increased markedly since 1970. The rates are similar across cultures as otherwise different as the United States, Japan, the United Kingdom, Australia, South Africa, Canada, France, Germany, and Israel. About 90% of patients diagnosed with bulimia are female as of 2002, but some researchers believe that the rate of bulimia among males is rising faster than the rate among females.

The average age at onset of bulimia nervosa appears to be dropping in the developed countries. A study of eating disorders in Rochester, Minnesota over the 50 years between 1935 and 1985 indicated that the incidence rates for women over 20 remained fairly constant, but there was a significant rise for women between 15 and 20 years of age. The average age at onset among women with bulimia was 14 and among men, 18.

In terms of sexual orientation, gay men appear to be as vulnerable to developing bulimia as heterosexual women, while lesbians are less vulnerable.

Recent studies indicate that bulimia in the United States is no longer primarily a disorder of Caucasian women; the rates among African American and Hispanic women have risen faster than the rate of bulimia for the female population as a whole. One report indicates that the chief difference between African American and Caucasian bulimics in the United States is that the African American patients are less likely to eat restricted diets between episodes of binge eating.

Diagnosis

The diagnosis of bulimia nervosa is made on the basis of a physical examination, a psychiatric assessment, the patient's eating history, and the findings of laboratory studies. Patients who do not meet the full criteria for bulimia nervosa may be given the diagnosis of subsyndromal bulimia or of eating disorder not otherwise specified (EDNOS).

Physical examination

Patients suspected of having bulimia nervosa should be given a complete physical examination because the disorder has so many potential medical complications. In addition, most bulimics are close to normal weight or only slightly overweight, and so do not look outwardly different from most people of their sex in their age group. The examination should include not only vital signs and an assessment of the patient's height and weight relative to age, but also checking for such signs of bulimia as general hair loss, abdominal soreness, swelling of the parotid glands, telltale scars on the back of the hand, petechiae, edema, and teeth that look ragged or "moth-eaten."

Psychiatric assessment

Psychiatric assessment of patients with bulimia usually includes four components:

• A thorough history of body weight, eating patterns, diets, typical daily food intake, methods of purging (if used), and concept of ideal weight.
• A history of the patient's significant relationships with parents, siblings, and peers, including present or past physical, emotional, or sexual abuse.
• A history of previous psychiatric treatment (if any) and assessment of comorbid (occurring at the same time as the bulimia) mood, anxiety, substance abuse, or personality disorders .
• Administration of standardized instruments that measure attitudes toward eating, body size, and weight. Common tests for eating disorders include the Eating Disorder Examination; the Eating Disorder Inventory; the Eating Attitude Test, or EAT; and the Kids Eating Disorder Survey.

Laboratory findings

Laboratory tests ordered for patients suspected of having bulimia usually include a complete blood cell count, blood serum chemistry, thyroid tests, and urinalysis. If necessary, the doctor may also order a chest x ray and an electrocardiogram (EKG). Typical findings in patients with bulimia include low levels of chloride and potassium in the blood, and higher than normal levels of amylase, a digestive enzyme found in saliva.

Treatments

Treatment for bulimia nervosa typically involves several therapy approaches. It is, however, complicated by several factors.

First, patients diagnosed with bulimia nervosa frequently have coexisting psychiatric disorders that typically include major depression, dysthymic disorder , anxiety disorders, substance abuse disorders, or personality disorders. In the case of depression, the mood disorder may either precede or follow the onset of bulimia, and, with bulimia, the prevalence of depression is 40%–70%. With regard to substance abuse, about 30% of patients diagnosed with bulimia nervosa abuse either alcohol or stimulants over the course of the eating disorder. The personality disorders most often diagnosed in bulimics are the so-called Cluster B disorders— borderline, narcissistic, histrionic, and antisocial. Borderline personality disorder is a disorder characterized by stormy interpersonal relationships, unstable self-image, and impulsive behavior. People with narcissistic personality disorder believe that they are extremely important and are unable to have empathy for others. Individuals with histrionic personality disorder seek attention almost constantly and are very emotional. Antisocial personality disorder is characterized by a behavior pattern of a disregard for others' rights— people with this disorder often deceive and mainpulate others. A number of clinicians have noted that patients with bulimia tend to develop impulsive and unstable personality disturbances whereas patients with anorexia tend to be more obsessional and perfectionistic. Estimates of the prevalence of personality disorders among patients with bulimia range between 2% and 50%. The clinician must then decide whether to treat the eating disorder and the comorbid conditions concurrently or sequentially. It is generally agreed, however, that a substance abuse disorder, if present, must be treated before the bulimia can be effectively managed. It is also generally agreed that mood disorders and bulimia can be treated concurrently, often using antidepressant medication along with therapy.

Second, the limitations on treatment imposed by managed care complicate the treatment of bulimia nervosa. When the disorder first received attention in the 1970s, patients with bulimia were often hospitalized until the most significant physical symptoms of the disorder could be treated. As of 2002, however, few patients with bulimia are hospitalized, with the exception of medical emergencies related to electrolyte imbalances and gastrointestinal injuries associated with the eating disorder. Most treatment protocols for bulimia nervosa now reflect cost-containment measures.

Medications

The most common medications given to patients are antidepressants, because bulimia is so closely associated with depression. Short-term medication trials have reported that tricyclic antidepressants— desipramine , imipramine , and amitriptyline — reduce episodes of binge eating by 47%–91% and vomiting by 45%–78%. The monoamine oxidase inhibitors are not recommended as initial medications for patients diagnosed with bulimia because of their side effects. The most promising results have been obtained with the selective serotonin reuptake inhibitors, or SSRIs. Fluoxetine (Prozac) was approved in 1998 by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa. Effective dosages of fluoxetine are higher for the treatment of bulimia than they are for the treatment of depression. Although a combination of medication and cognitive-behavioral therapy is more effective in treating most patients with bulimia than medication alone, one team of researchers reported success in treating some bulimics who had not responded to psychotherapy with fluoxetine by itself.

A newer type of medication that shows promise in the treatment of bulimia nervosa is ondansetron, a drug that was originally developed to control nausea from chemotherapy and radiation therapy for cancer. Ondansetron acts to control the transmission of signals in nerves leading to the vagus nerve, which in turn governs feelings of fullness and the vomiting reflex. A British study reported that ondansetron normalized several aspects of eating behaviors in all the patients who received it during the study.

In addition to antidepressant or antinausea medications, such acid-reducing medications as cimetidine and ranitidine, or antacids, may be given to patients with bulimia to relieve discomfort in the digestive tract associated with irritation caused by stomach acid.

Psychotherapy

Cognitive-behavioral therapy (CBT) is regarded as the most successful psychotherapeutic approach to bulimia nervosa. CBT is intended to interrupt the faulty thinking processes associated with bulimia, such as preoccupations with food and weight, black-white thinking ("all or nothing" thinking, or thinking thoughts only at extreme ends of a spectrum) and low self-esteem, as well as such behaviors as the binge-purge cycle. Patients are first helped to regain control over their food intake by keeping food diaries and receiving feedback about their meal plans, symptom triggers, nutritional balance, etc. They are then taught to challenge rigid thought patterns as well as receiving assertiveness training and practice in identifying and expressing their feelings in words rather than through distorted eating patterns. About 50% of bulimic patients treated with CBT are able to stop bingeing and purging. Of the remaining half, some show partial improvement and a small minority do not respond at all.

Family therapy is sometimes recommended as an additional mode of treatment for patients with bulimia who come from severely troubled or food-obsessed families that increase their risk of relapsing.

Other mainstream therapies

Medical nutrition therapy, or MNT, is a recognized component of the treatment of eating disorders. Effective MNT for patients with bulimia involves an understanding of cognitive-behavioral therapy as well as the registered dietitian's usual role of assisting the physician with monitoring the patient's physical symptoms, laboratory values, and vital signs. In the treatment of bulimia, the dietitian's specialized knowledge of nutrition may be quite helpful in dealing with the myths about food and fad diets that many bulimic patients believe. The dietitian's most important task, however, is helping the patient to normalize her or his eating patterns in order to break the deprivation/bingeing cycle that is characteristic of bulimia nervosa. Calorie intake is usually based on retaining the patient's weight in order to prevent hunger, since hunger increases susceptibility to bingeing.

Recent studies in upstate New York have found that bright light therapy , of the type frequently prescribed for seasonal affective disorder (SAD), appears to be effective in reducing binge eating in patients diagnosed with bulimia. It also significantly relieved depressive symptoms, as measured by the patients' scores on the Beck Depression Inventory .

Alternative and complementary treatments

Alternative therapies that have been shown to be helpful for some patients in relieving the anxiety and muscular soreness associated with bulimia nervosa include acupuncture , massage therapy, hydrotherapy, and shiatsu.

Herbal remedies that have been used to calm digestive upsets in bulimic patients include teas made from chamomile or peppermint. Peppermint helps to soothe the intestines by slowing down the rate of smooth muscle contractions (peristalsis). Chamomile has been used to help expel gas from the digestive tract, a common complaint of bulimics. Both herbs have a wide margin of safety.

Some bulimic patients have responded well to yoga because its emphasis on focused breathing and meditation calls attention to and challenges the distorted thought patterns that characterize bulimia. In addition, the stretching and bending movements that are part of a yoga practice help to displace negative thoughts focused on the body's outward appearance with positive appreciation of its strength and agility. Lastly, since yoga is noncompetitive, it allows bulimics to explore the uniqueness of their bodies rather than constantly comparing themselves to other people.

Prognosis

The prognosis of bulimia depends on several factors, including age at onset, types of purging behaviors used (if any), and the presence of other psychiatric conditions or disorders. In many cases, the disorder becomes a chronic (long-term) condition; 20%–50% of patients have symptoms for at least five years in spite of treatment. The usual pattern is an alternation between periods of remission and new episodes of bingeing. Patients whose periods of remission last for a year or longer have a better prognosis; patients diagnosed with major depression or a personality disorder have a less favorable prognosis. Overall, however, the prognosis for full recovery from bulimia nervosa is considered relatively poor compared to other eating disorders.

Bulimia nervosa appears to produce changes in the functioning of the serotonin system in the brain. Serotonin is a neurotransmitter. A team of researchers at the University of Pittsburgh who compared brain images taken by positron emission tomography (PET) from bulimic women who had been in remission for a year or longer with brain images from healthy women found that the recovered bulimics did not have a normal age-related decline in serotonin binding. Since serotonin helps to regulate mood, appetite, and impulse control, the study may help to explain why some women may be more susceptible to developing bulimia than others.

Prevention

As of 2002, the genetic factors in bulimia are not well understood. With regard to family influences, an important study published in December 2001 reported that the presence of eating problems in early childhood is a strong predictor of eating disorders in later life. The longitudinal study of 800 children and their mothers was based on psychiatric assessments of the subjects made in 1975, 1983, 1985, and 1992. The researchers found that a diagnosis of bulimia nervosa in early adolescence is associated with a nine-fold increase in risk for late adolescent bulimia and a 20-fold increase in risk for adult bulimia. Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. Given these findings, the most important preventive measure that can be taken in regard to bulimia nervosa is the establishment of healthful eating patterns and attitudes toward food in the family of origin.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

"Bulimia Nervosa." Section 15, Chapter 196 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Chernin, Kim. The Obsession: Reflections on the Tyranny of Slenderness. Revised edition. New York: HarperPerennial Editions, 1994.

Eichenbaum, Luise, and Susie Orbach. Understanding Women: A Feminist Psychoanalytic Approach. New York: Basic Books, Inc., Publishers, 1983.

Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: HarperPerennial Editions, 1999.

Newmark, Gretchen Rose. "Overcoming Eating Disorders." In Living Yoga: A Comprehensive Guide for Daily Life, edited by Georg Feuerstein and Stephan Bodia. New York: Jeremy P. Tarcher/Perigee, 1993.

Rodin, Judith, PhD. Body Traps: Breaking the Binds That Keep You from Feeling Good About Your Body. New York: William Morrow, 1992.

Roth, Geneen. When Food is Love. New York: Penguin Books, 1992.

Wolf, Naomi. The Beauty Myth: How Images of Beauty Are Used Against Women. New York: Anchor Books, 1992.

PERIODICALS

Bulik, C. M., etal. "Twin Studies of Eating Disorders: A Review." International Journal of Eating Disorders 27 (2000): 1-20.

Eliot, A. W., and C. W. Baker. "Eating Disordered Adolescent Males." Adolescence 36 (Fall 2001): 535-543.

Fairburn, Christopher C. "The Natural Course of Bulimia Nervosa and Binge Eating Disorder in Young Women." Journal of the American Medical Association 284 (October 18, 2000): 1906.

Hay, Phillipa J., and Josue Bacaltchuk. "Bulimia Nervosa: Review of Treatments." British Medical Journal 303 (July 7, 2001): 33-37.

Kaye, Walter H., Guido K. Frank, Carolyn C. Meltzer, and others. "Altered Serotonin 2A Receptor Activity in Women Who Have Recovered From Bulimia Nervosa." American Journal of Psychiatry 158 (July 2001): 1152-1155.

Kotler, Lisa A., Patricia Cohen, Mark Davies, and others. "Longitudinal Relationships Between Childhood, Adolescent, and Adult Eating Disorders." Journal of the American Academy of Child and Adolescent Psychiatry 40 (December 2001): 1434-1440.

"Light Therapy for Bulimia." Family Practice News 10 (February 1, 2000): 32.

Little, J. W. "Eating Disorders: Dental Implications." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 93 (February 2002): 138-143.

McGilley, Beth M., and Tamara L. Pryor. "Assessment and Treatment of Bulimia Nervosa." American Family Physician 57 (June 1998): 1339.

Miller, Karl E. "Cognitive Behavior Treatment of Bulimia Nervosa." American Family Physician 63 (February 1, 2001): 536.

"Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified." Journal of the American Dietetic Association 101 (July 2001): 810-828.

Romano, Steven J., Katherine A. Halmi, Neena P. Sankar, and others. "A Placebo-Controlled Study of Fluoxetine in Continued Treatment of Bulimia Nervosa After Successful Acute Fluoxetine Treatment." American Journal of Psychiatry 159 (January 2002): 96-102.

Steiger, Howard, Lise Gauvin, Mimi Israel, and others. "Association of Serotonin and Cortisol Indices with Childhood Abuse in Bulimia Nervosa." Archives of General Psychiatry 58 (September 2001): 837.

Vink, T., A. Hinney, A. A. van Elburg, and others. "Association Between an Agouti-Related Protein Gene Polymorphism and Anorexia Nervosa." Molecular Psychiatry 6 (May 2001): 325-328.

Walling, Anne D. "Anti-Nausea Drug Promising in Treatment of Bulimia Nervosa." American Family Physician 62 (September 1, 2000): 1156.

ORGANIZATIONS

Academy for Eating Disorders. Montefiore Medical School, Adolescent Medicine, 111 East 210th Street, Bronx, NY 10467. (718) 920-6782.

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.

American Anorexia/Bulimia Association. 165 West 46th Street, Suite 1108, New York, NY 10036. (212) 575-6200.

American Dietetic Association. (800) 877-1600. <www.eatright.org>.

Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED). P.O. Box 5102, Eugene, OR 97405. (541) 344-1144. <www.anred.com>.

Center for the Study of Anorexia and Bulimia. 1 W. 91st St., New York, NY 10024. (212) 595-3449.

Rebecca J. Frey, Ph.D.

Bulimia nervosa

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatment

Nutrition/Dietetic concerns

Therapy

Prognosis

Prevention

Resources

Definition

Bulimia nervosa is an eating disorder that involves repeated binge eating followed by purging the body of calories to avoid gaining weight. The person who has bulimia has an irrational fear of gaining weight and a distorted body image. Bulimia nervosa can have potentially fatal health consequences. .

Description

Bulimia is an eating disorder whose main feature is eating an unreasonably large amount of food in a short time, then following this binge by purging the body of calories. Purging is most often done by self-induced vomiting, but it can also be done by laxative, enema, or diuretic abuse. Alternately, some people with bulimia do not purge but use extreme exercising and post-binge fasting to burn calories. This can lead to serious injury. Nonpurging bulimia is sometimes called exercise bulimia. Bulimia nervosa is officially recognized as a psychiatric disorder in the Diagnostic

Effects of bulimia on the body

source: National Women’s Health Information Center, Office on Women’s Health, U.S. Department of Health and Human Services.

(llustration by GGS Information Services/Thomson Gale)

and Statistical Manual for Mental Disorders Fourth Edition-Text Revision (DSM-IV-TR)published by the American Psychiatric Association.

Bulimia nervosa is diagnosed when most of the following conditions are present:

• Repeated episodes of binge eating followed by behavior to compensate for the binge (i.e. purging, fasting, over-exercising). Binge eating is defined as eating a significantly larger amount of food in a limited time than most people typically would eat.
• Binge/purge episodes occur at least twice a week for a period of three or more months.
• The individual feels unable to control or stop an eating binge once it starts and will continue to eat even if uncomfortably full.
• The individual is overly concerned about body weight and shape and puts unreasonable emphasis on physical appearance when evaluating his or her self-worth.
• Bingebingeinging and purging does not occur exclusively during periods of anorexia nervosa.

Many people with bulimia will consume 3,000-10,000 calories in an hour. For example, they will start out intending to eat one slice of cake and end up eating the entire cake. One distinguishing aspect of bulimia is how out of control people with bulimia feel when they are eating. They will eat and eat, continuing even when they feel full and become uncomfortable.

Most people with bulimia recognize that their behavior is not normal; they simply cannot control it. They usually feel ashamed and guilty over their binge/purge habits. As a result, they frequently become secretive about their eating and purging. They may, for example, eat at night after the family has gone to bed or buy food at the grocery store and eat it in the car before going home. Many bulimics choose high-fat, high-sugar foods that are easy to eat and easy to regurgitate. They become adept at inducing vomiting, usually by sticking a finger down their throat and triggering the gag reflex. After a while, they can vomit at will. Repeated purging has serious physical and emotional consequences.

Many individuals with bulimia are of normal weigh, and a fair number of men who become bulimic were overweight as children. This makes it difficult for family and friends to recognize that someone suffering from this disorder. People with bulimia often lie about induced vomiting and laxative abuse, although they may complain of symptoms related to their binge/ purge cycles and seek medical help for those problems. People with bulimia tend to be more impulsive than people with other eating disorders. Lack of impulse control often leads to risky sexual behavior, anger management problems, and alcohol and drug abuse.

A subset of people with bulimia also have anorexia nervosa. Anorexia nervosa is an eating disorder that involves self-imposed starvation. These people often purge after eating only a small or a normal-sized portion of food. Some studies have shown that up to 60% of people with bulimia have a history of anorexia nervosa.

Dieting is usually the trigger that starts a person down the road to bulimia. The future bulimic is very concerned about weight gain and appearance, and may constantly be on a diet. She (most people with bulimia are female) may begin by going on a rigorous low-calorie diet. Unable to stick with the diet, she then

KEY TERMS

Diuretic —A substance that removes water from the body by increasing urine production.

Electrolyte —Ions in the body that participate in metabolic reactions. The major human electrolytes are sodium (Na+), potassium (K+), calcium (Ca 2+), magnesium (Mg2+), chloride (Cl—), phosphate (HPO₄ 2-), bicarbonate (HCO3-), and sulfate (SO₄ 2-).

Neurotransmitter —One of a group of chemicals secreted by a nerve cell (neuron) to carry a chemical message to another nerve cell, often as a way of transmitting a nerve impulse. Examples of neurotransmitters include acetylcholine, dopamine, serotonin, and norepinephrine.

Obsessive-compulsive disorder —A psychiatric disorder in which a person is unable to control the desire to repeat the same action over and over.

eats voraciously far more than she needs to satisfy her hunger, feels guilty about eating, and then exercise or purges to get rid of the unwanted calories. At first this may happen only occasionally, but gradually these sessions of bingeing and purging become routine and start to intrude on the person’s friendships, daily activities, and health. Eventually these practices have serious physical and emotional consequences that need to be addressed by healthcare professionals.

Demographics

Bulimia nervosa is primarily a disorder of industrialized countries where food is abundant and the culture values a thin appearance. Internationally, the rate of bulimia has been increasing since the 1950s. Bulimia is the most common eating disorder in the United States. Overall, about 3% of Americans are bulimic. Of these 85–90% are female. The rate is highest among adolescents and college women, averaging 5–6%. In men, the disorder is more often diagnosed in homosexuals than in heterosexuals. Some experts believe that number of diagnosed bulimics represents only the most severe cases and that many more people have bulimic tendencies, but are successful in hiding their symptoms. In one study, 40% of college women reported isolated incidents of bingeing and purging.

Bulimia affects people from all racial, ethnic, and socioeconomic groups. The disorder usually begins later in life than anorexia nervosa. Most people begin bingeing and purging in their late teens through their twenties. Men tend to start at an older age than women. About 5% of people with bulimia begin the behavior after age 25. Bulimia is uncommon in children under age 14.

Competitive athletes have an increased risk of developing bulimia nervosa, especially in sports where weight it tied to performance and where a low percentage of body fat is highly desirable. Jockeys, wrestlers, bodybuilders, figure skaters, cross-country runners, and gymnasts have higher than average rates of bulimia. People such as actors, models, cheerleaders, and dancers who are judged mainly on their appearance are also at high risk of developing the disorder. This same group of people is also at higher risk for developing anorexia nervosa. Some people are primarily anorexic and severely restrict their calorie intake while also purging the small amounts they do eat. Others move back and forth between anorectic and bulimic behaviors.

Causes and symptoms

Bulimia nervosa is a complex disorder that does not have a single cause. Research suggests that some people have a predisposition toward bulimia and that something then triggers the behavior, which then becomes self-reinforcing. Hereditary, biological, psychological and social factors all appear to play a role.

Causes

• Heredity. Twin studies suggest that there is an inherited component to bulimia nervosa, but that it is small. Having a close relative, usually a mother or a sister, with bulimia slightly increases the likelihood of other (usually female) family members developing the disorder. However, when compared other inherited diseases or even to anorexia nervosa, the genetic contribution to developing this disorder appears less important than many other factors. Family history of depression, alcoholism, and obesity also increase the risk of developing bulimia.
• Biological factors. There is some evidence that bulimia is linked low levels of serotonin in the brain. Serotonin is a neurotransmitter. One of its functions is to help regulate the feeling of fullness or satiety that tells a person to stop eating. Neurotransmitters are also involved in other mental disorders such as depression that often occur with bulimia. Other research suggests that people with bulimia may have abnormal levels of leptin, a protein that helps regulate weight by telling the body to take in less food. Research in this area is relatively new, and the findings are still unclear.
• Psychological factors. Certain personality types appear to be more vulnerable to developing bulimia. People with bulimia tend to have poor impulse control. They are of often involved in risky behavior such as shoplifting, drug and alcohol abuse and risky sexual activities. People with bulimia have low-self worth and depend on the approval of others to feel good about themselves. They are aware that their behavior is abnormal. After a binge/purge session, they are ashamed and vow never to repeat the cycle, but the next time they are unable to control the impulse to eat and purge. They also tend to have a black-or-white, all-or-nothing way of seeing situations. Major depression, obsessive-compulsive disorder, and anxiety disorders are more common among individuals who are bulimic.
• Social factors. The families of people who develop bulimia are more likely to have members who have problems with alcoholism, depression, and obesity. These families also tend to have a high level of open conflict and disordered, unpredictable lives. Often something stressful or upsetting triggers the urge to diet stringently and then begin binge/purge behaviors. This may be as simple as a family member as teasing about the person’s weight, nagging about eating junk food, commenting on how clothes fit, or comparing the person unfavorably to someone who is thin. Life events such as moving, starting a new school, and breaking up with a boyfriend can also trigger binge/purge behavior. Overlaying the family situation is the false, but unrelenting, media message that thin is good and fat is bad; thin people are successful, glamorous, and happy, fat people are stupid, lazy, and failures.

Signs and symptoms

• Binge/purge cycles have physical consequences. These include:
• teeth damaged from repeated exposure to stomach acid from vomiting; eroded tooth enamel;
• swollen salivary glands; sores in mouth and throat
• dehydration
• sores or calluses on knuckles or hands from using them to induce vomiting
• electrolyte imbalances revealed by laboratory tests
• dry skin
• fatigue
• irregular or absent menstrual cycles in women
• weight, heart rate and blood pressure may be normal

Diagnosis

Diagnosis is based on several factors including a patient history, physical examination, the results of laboratory tests, and a mental status evaluation. A patient history is less helpful in diagnosing bulimia than in diagnosing many diseases because many people with bulimia lie about their bingeing and purging and their use of laxatives, enemas, and medications. The patient may, however, complain about related symptoms such as fatigue or feeling bloated. Many people with bulimia express extreme concern about their weight during the examination.

A physical examination begins with weight and blood pressure and moves through the body looking for the signs listed above. Based on the physical exam and patient history, the physician will order laboratory tests. In general these tests will include a complete blood count (CBC), urinalysis, and blood chemistries (to determine electrolyte levels). People suspected of being exercise bulimic may need to have x rays to look for damage to bones from over-exercising.

Several different evaluations can be used to examine a person’s mental state. A doctor or mental health professional will assess the individual’s thoughts and feelings about themselves, their body, their relationships with others, and their risk for self-harm.

Treatment

Treatment choices depend on the degree to which the bulimic behavior has resulted in physical damage and whether the person is a danger to him or herself. Hospital impatient care may be needed to correct severe electrolyte imbalances that result from repeated vomiting and laxative abuse. Electrolyte imbalances can result in heart irregularities and other potentially fatal complications. Most people with bulimia do not require hospitalization. The rate of hospitalization is much lower than that for people with anorexia nerv-osa because many bulimics maintain a normal weight.

Day treatment or partial hospitalization where the patient goes every day to an extensive treatment program provides structured mealtimes, nutrition education, intensive therapy, medical monitoring, and supervision. If day treatment fails, the patient may need to be hospitalized or enter a full-time residential treatment facility.

Outpatient treatment provides medical supervision, nutrition counseling, self-help strategies, and psychotherapy. Self-help groups receive mixed reviews from healthcare professionals who work with bulimics. Some groups offer constructive support in stopping the binge/purge cycle, while others tend to reinforce the behavior.

Drug therapy helps many people with bulimia. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) have been approved by the United States Food and Drug Administration (FDA) for treatment of bulimia. These medications increase serotonin levels in the brain and are thought to affect the body’s sense of fullness. They are used whether or not the patient shows signs of depression. Drug treatment should always be supplemented with psychotherapy. (see Therapies below).

Other drugs are being explored for use in the treatment of bulimia. Individuals with bulimia interested in entering a clinical trial at no cost can find a list and description of clinical trials currently enrolling volunteers at http://www.clinicaltrials.gov.

Nutrition/Dietetic concerns

A nutrition consultant or dietitian is part of the team needed to successfully treat bulimia. These professionals usually do a dietary review along with nutritional counseling so that the recovering bulimic can plan healthy meals and develop a healthy relationship with food.

Therapy

Medical intervention helps alleviate the immediate physical problems associated with bulimia. Medication can help the person with bulimia break the binge/purge cycle. However drug therapy alone rarely produces recovery. Psychotherapy plays a major role helping the individual with bulimia recover from the disorder. Several different types of psychotherapy are used depending on the individual’s situation. Generally, the goal of psychotherapy is help the individual change his or her behavior and develop a healthy attitude toward their body and food.

Some types of psychotherapy that have been successful in treating people with bulimia are listed below.

• Cognitive behavior therapy (CBT) is designed to confront and then change the individual’s thoughts and feelings about his or her body and behaviors toward food, but it does not address why those thoughts or feelings exist. Strategies to maintain self-control may be explored. This therapy is relatively short-term. CBT is often the therapy of choice for people with bulimia, and it is often successful at least in the short term.
• Interpersonal therapy is short-term therapy that helps the individual identify specific issues and problems in relationships. The individual may be asked to look back at his or her family history to try to recognize problem areas and work toward resolving them. Interpersonal therapy has about the same rate of success in people with bulimia as CBT.
• Family and/or couples therapy is helpful in dealing with conflict or disorder that may be a factor in triggering binge/purge behavior at home.
• Supportive-expressive therapy or group therapy may be helpful in addition to other types of therapy.

Prognosis

The long-term outlook for recovery from bulimia is mixed. About half of all bulimics show improvement in controlling their behavior after short-term interpersonal or cognitive behavioral therapy with nutritional counseling and drug therapy. However, after three years, only about one-third are still doing well. Relapses are common, and binge/purge episodes and bulimic behavior often comes and goes for many years. Stress seems to be a major trigger for relapse.

The sooner treatment is sought, the better the chances of recovery. Without professional intervention, recovery is unlikely. Untreated bulimia can lead to death directly from causes such as rupture of the stomach or esophagus. Associated problems such as substance abuse, depression, anxiety disorders, and poor impulse control also contribute to the death rate.

Prevention

Some ways to prevent bulimia nervosa from developing are as follows:

• If you are a parent, do not obsess about your own weight, appearance, and diet in front of your children.
• Do not tease your children about their body shapes or compare them to others.
• Make it clear that you love and accept your children as they are.
• Try to eat meals together as a family whenever possible.
• Remind children that the models they see on television and in fashion magazines have extreme, not normal or healthy bodies.
• Do not put your child on a diet unless advised to by your pediatrician.
• Block your child from visiting pro-bulimia Websites. These are sites where people with bulimia give advice.
• on how to purge and support each other’s binge/ purge behavior.
• If your child is a competitive athlete, get to know the coach and the coach’s attitude toward weight.
• be alert to signs of low self-worth, anxiety, depression, and drug or alcohol abuse and seek help as soon as these signs appear.
• If you think your child has an eating disorder, do not wait to intervene and the professional help. The sooner the disorder is treated, the easier it is to cure.

Relapses happen to many people with bulimia. People who are recovering from bulimia can help prevent themselves from relapsing by:

• never dieting; instead plan healthy meals
• eating with other people, not alone
• staying in treatment; keep therapy appointments
• monitoring negative self-talk; practicing positive self-talk
• spending time doing something enjoyable every day
• staying busy, but not overly busy; getting at least seven hours of sleep each night
• spending time each day with people you care about and who care about you

Resources

BOOKS

Carleton, Pamela and Deborah Ashin. Take Charge of Your Child’s Eating Disorder: A Physician’s Step-By-Step Guide to Defeating Anorexia and BulimiaNew York: Marlowe & Co., 2007.

Heaton, Jeanne A. and Claudia J. Strauss. Talking to Eating Disorders: Simple Ways to Support Someone Who Has Anorexia, Bulimia, Binge Eating or Body Image IssuesNew York, NY: New American Library, 2005.

Kolodny, Nancy J. The Beginner’s Guide to Eating Disorders RecoveryCarlsbad, CA: Gurze Books, 2004.

McCabe, Randi E., Traci L. McFarlane, and Marion P. Olmsted. The Overcoming Bulimia Workbook: Your Comprehensive, Step-By-Step Guide to RecoveryOakland, CA: New Harbinger, 2004.

Messinger, Lisa and Merle Goldberg. My Thin Excuse: Understanding, Recognizing, and Overcoming Eating DisordersGarden City Park, NY: Square One Publishers, 2006.

Rubin, Jerome S., ed. Eating Disorders and Weight Loss ResearchHauppauge, NY: Nova Science Publishers, 2006.

Walsh, B. Timothy. If Your Adolescent Has an Eating Disorder: An Essential Resource for ParentsNew York, NY: Oxford University Press, 2005.

PERIODICALS

“Surfing for Thinness: A Pilot Study of Pro-Eating Disorder Web Site Usage in Adolescents With Eating Disorders.” Pediatrics 118, no. 6 (December 2006): e1635-43. <http://pediatrics.aappublications.org/cgi/content/full/118/6/e1635>

ORGANIZATIONS

American Psychological Association. 750 First Street, NE, Washington, DC 20002-4242. Telephone: (800) 374-2721; (202) 336-5500. TDD/TTY: (202)336-6123. Website: <http://www.apa.org>

National Association of Anorexia Nervosa and Associated Disorders (ANAD). P.O. Box 7 Highland Park, IL 60035. Telephone: (847) 831-3438. Website: <http://www.anad.org>

National Eating Disorders Association. 603 Stewart Street, Suite 803, Seattle, WA 98101. Help and Referral Line: (800) 931-2237. Office Telephone: (206) 382-3587. Website: <http://www.edap.org>

OTHER

Anorexia Nervosa and Related Eating Disorders. “Athletes With Eating Disorders.” October 6, 2006.<http://www.anred.com/ath.html>

Anorexia Nervosa and Related Eating Disorders. “The Better-Known Eating Disorders.” January 16, 2006. <http://www.anred.com/defswk.html>

Anorexia Nervosa and Related Eating Disorders. “Eating Disorders and Pregnancy.” October 18, 2006. <http://www.anred.com/pg.html>

Anorexia Nervosa and Related Eating Disorders. “Males With Eating Disorders.” February 6, 2007. <http://www.anred.com/males.html>

Foster, Tammy, “Bulimia.” emedicine.com February 2, 2007. <http://www.emedicine.com/emerg/topic810.htm>

Mayo Clinic Staff. “Bulimia nervosa.”MayoClinic.com, May 13, 2006. <http://www.mayoclinic.com/health/bulimia/DS00607>

Medline Plus. “Eating Disorders.” U. S. National Library of Medicine, April 2, 2007. <http://www.nlm.nih/gov/medlineplus/eatingdisorders.html>

National Association of Anorexia Nervosa and Associated Disorders “Facts About Eating Disorders.”undated; accessed April 3, 2007. <http://www.anad.org/>

National Association of Anorexia Nervosa and Associated Disorders “Facts About Eating Disorders.” undated; accessed April 3, 2007. <http://www.anad.org/>

Uwaifo, Gabriel and Robert C. Daly. “Bulimia.” emedici-ne.com December 1, 2006. <http://www.emedicine.-com/med/topic255.htm>

Tish Davidson, A.M.

Bulimia nervosa

Definition

Bulimia nervosa is a serious and sometimes life-threatening eating disorder affecting mainly young women. People with bulimia, known as bulimics, consume large amounts of food (binge) and then try to rid themselves of the food and calories (purge) by fasting, excessive exercise, vomiting , or using laxatives . The behavior often serves to reduce stress and relieve anxiety . Because bulimia results from an excessive concern with weight control and self-image and is often accompanied by depression, it is also considered to be a psychiatric illness.

Description

Bulimia nervosa is a serious health problem for over 2 million adolescent girls and young women in the United States. The bingeing and purging activity associated with this disorder can cause severe damage, even death, although the risk of death is not as high as for anorexia nervosa , an eating disorder that leads to excessive weight loss.

In rare instances, binge eating may cause the stomach to rupture. In the case of purging, heart failure can result due to loss of vital minerals such as potassium. Vomiting causes other serious problems, including acid-related scarring of the fingers (if used to induce vomiting) and damage to tooth enamel. In addition, the tube that delivers food from the mouth to the stomach (the esophagus) often becomes inflamed, and salivary glands can become swollen. Irregular menstrual periods can also result, and interest in sex may diminish.

Most bulimics find it difficult to stop their behavior without professional help. Many typically recognize that the behavior is not normal, but they feel helpless to control it. Some bulimics struggle with other compulsive, risky behaviors such as drug and alcohol abuse. Many also suffer from other psychiatric illnesses, including clinical depression, anxiety, and obsessive-compulsive disorder (OCD).

Bulimic behavior is often carried out in secrecy, accompanied by feelings of guilt or shame. Outwardly, many people with bulimia appear healthy and successful, while inside they have feelings of helplessness and low self-esteem .

Demographics

Most bulimics are females in their teens to early 20s. Males account for only 5 to 10 percent of all cases. People of all races develop the disorder, but most of those diagnosed are white.

Causes and symptoms

The cause of bulimia is as of 2004 unknown. Researchers believe that it may be caused by a combination of genetic and environmental factors. Bulimia tends to run in families. Research shows that certain brain chemicals, known as neurotransmitters, may function abnormally in acutely ill people with bulimia nervosa. Scientists also believe there may be a link between bulimia and other psychiatric problems, such as depression and OCD. Environmental influences include participation in work or sports that emphasize thinness, such as modeling, dancing, or gymnastics. Family pressures also may play a role. One study found that mothers who are extremely concerned about their daughters' physical attractiveness and weight may in part cause bulimia in them. In addition, girls with eating disorders tend to have fathers and brothers who criticize their weight. Bulimia tends to run in families.

According to the American Anorexia/Bulimia Association Inc., warning signs of bulimia include the following:

• eating large amounts of food uncontrollably (bingeing)
• vomiting, abusing laxatives or diuretics, or engaging in fasting, dieting, or vigorous exercise (purging)
• preoccupation with body weight
• using the bathroom frequently after meals
• depression or mood swings
• irregular menstrual periods
• onset of dental problems, swollen cheeks or glands, heartburn, or bloating

When to call the doctor

A healthcare professional should be consulted at the first sign of behaviors associated with bulimia.

Diagnosis

Bulimia is treated most successfully when diagnosed early. However, because the bulimic may deny there is a problem, getting medical help is often delayed. A complete physical examination in order to rule out other illnesses is the first step to diagnosis.

According to the American Psychiatric Association, a diagnosis of bulimia requires that a person have all of the following symptoms:

• recurrent episodes of binge eating (minimum average of two binge-eating episodes a week for at least three months)
• a feeling of lack of control over eating during the binges
• regular use of one or more of the following to prevent weight gain: self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise
• persistent over-concern with body shape and weight

Treatment

Early treatment is important; otherwise, bulimia may become chronic, with serious health consequences. A comprehensive treatment plan is called for in order to address the complex interaction of physical and psychological problems in bulimia. A combination of drug and behavioral therapies is commonly used.

Behavioral approaches include individual psychotherapy, group therapy, and family therapy . Cognitive-behavioral therapy, which teaches people how to change abnormal thoughts and behavior, is also used. Nutrition counseling and self-help groups are often helpful.

Antidepressants commonly used to treat bulimia include desipramine (Norpramin), imipramine (Tofranil), and fluoxetine (Prozac). These medications also may treat any co-existing depression.

In addition to professional treatment, family support plays an important role in helping the bulimic person. Encouragement and emotional support may convince the sick person to get help, stay with treatment, or try again

after a failure. Family members can help locate resources, such as eating disorder clinics in local hospitals or treatment programs in colleges designed for students.

Light therapy—exposure to bright, artificial light—may be useful in reducing bulimic episodes, especially during the dark winter months. Some feel that massage may prove helpful, putting people in touch with the reality of their own bodies and correcting misconceptions of body image. Hypnotherapy may help resolve unconscious issues that contribute to bulimic behavior.

Prognosis

Bulimia may become chronic and lead to serious health problems, including seizures, irregular heartbeat, and thin bones. In rare cases, it may be fatal. Timely therapy and medication can effectively manage the disorder and help the bulimic live a normal, productive, and fulfilling life.

Prevention

There is as of 2004 no known method for preventing bulimia. However, parents can promote healthy eating habits in their children and encourage them to embrace realistic, rather than overly thin, body images.

Nutritional concerns

Abnormal food intake and purging may result in abnormal nutrition. Purging may lead to a loss of potassium and other essential metabolic ions. These can become life threatening.

Parental concerns

Parental remarks about body size and shape often trigger bulimia. Parents of bulimics must be supportive and participate in treatment if the condition is to be successfully treated.

KEY TERMS

Binge —A pattern of eating marked by episodes of rapid consumption of large amounts of food; usually food that is high in calories.

Diuretics —A group of drugs that helps remove excess water from the body by increasing the amount lost by urination.

Neurotransmitters —Chemicals in the brain that transmit nerve impulses.

Obsessive-compulsive disorder —An anxiety disorder marked by the recurrence of intrusive or disturbing thoughts, impulses, images, or ideas (obsessions) accompanied by repeated attempts to supress these thoughts through the performance of certain irrational and ritualistic behaviors or mental acts (compulsions).

Purge —To rid the body of food and calories, commonly by vomiting or using laxatives.

See also Binge eating disorder.

Resources

BOOKS

Bendich, Adrianne, and David J. Goldstein. Management of Eating Disorders and Obesity, 2nd ed. Totawa, NJ: Humana Press, 2004.

Litt, Iris F. "Anorexia Nervosa and Bulimia." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, et al. Philadelphia: Saunders, 2003, pp. 652–3.

Smith, Grainne. Anorexia and Bulimia in the Family: One Parent's Practical Guide to Recovery. New York: Wiley & Sons, 2004.

Walsh, B. Timothy. "Eating Disorders." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald, et al. New York: McGraw Hill, 2001, pp. 486–90.

West, Delia Smith. "The Eating Disorders." In Cecil Textbook of Medicine, 22nd ed. Edited by Lee Goldman, et al. Philadelphia: Saunders, 2003, pp. 1326–35.

PERIODICALS

Burns, M., and N. Gavey. "Healthy weight at what cost? Bulimia and a discourse of weight control." Journal of Health Psychology 9, no. 4 (2004): 249–65.

Crow, S. J., et al. "Bulimia symptoms and other risk behaviors during pregnancy in women with bulimia nervosa." International Journal of Eating Disorders 36, no. 2 (2004): 220–3.

Hinney A., et al. "Genetic risk factors in eating disorders." American Journal of Pharmacogenomics 4, no. 4 (2004): 209–23.

Morad, M., I. Kandel, and J. Merrick. "Anorexia and bulimia in the family." International Journal of Adolescent Medicine and Health 16, no. 2 (2004): 89–90.

ORGANIZATIONS

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org/>.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: <www.aap.org/default.htm>.

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Web site: <www.psych.org/>.

American Psychological Association. 750 First Street NW, Washington, DC, 20002–4242. Web site: <www.apa.org/>.

National Eating Disorders Organization (NEDO). 6655 South Yale Ave, Tulsa, OK 74136. Web site: <www.NationalEatingDisorders.org>.

WEB SITES

"Bulimia." National Alliance for the Mentally Ill. Available online at <www.nami.org/Template.cfm?Section=By_Illness&amp;template=/ContentManagement/ContentDisplay.cfm&amp;ContentID=7638> (accessed November 2, 2004).

"Bulimia." National Library of Medicine. Available online at <www.nlm.nih.gov/medlineplus/ency/article/000341.htm> (accessed November 2, 2004).

"Bulimia and Related Disorders." Northern Arizona University. Available online at <http://dana.ucc.nau.edu/~kdk2/bulimia.html> (accessed November 2, 2004).

"Bulimia Nervosa." Internet Mental Health. Available online at <www.mentalhealth.com/dis/p20-et02.html> (accessed November 2, 2004).

L. Fleming Fallon, Jr., MD, DrPH

Bulimia Nervosa

Definition

Bulimia nervosa is a serious and sometimes life-threatening eating disorder affecting mainly young women. People with bulimia, known as bulimics, consume large amounts of food (binge) and then try to rid themselves of the food and calories (purge) by fasting, excessive exercise, vomiting, or using laxatives. The behavior often serves to reduce stress and relieve anxiety. Because bulimia results from an excessive concern with weight control and self-image, and is often accompanied by depression, it is also considered a psychiatric illness.

Description

Bulimia nervosa is a serious health problem for over two million adolescent girls and young women in the United States. The bingeing and purging activity associated with this disorder can cause severe damage, even death, although the risk of death is not as high as for anorexia nervosa, an eating disorder that leads to excessive weight loss.

Binge eating may in rare instances cause the stomach to rupture. In the case of purging, heart failure can result due to loss of vital minerals such as potassium. Vomiting causes other serious problems, including acid-related scarring of the fingers (if used to induce vomiting) and damage to tooth enamel. In addition, the tube that brings food from the mouth to the stomach (the esophagus) often becomes inflamed and salivary glands can become swollen. Irregular menstrual periods can also result, and interest in sex may diminish.

KEY TERMS

Binge— To consume large amounts of food uncontrollably within a short time period.

Diuretic— A drug that promotes the formation and excretion of urine.

Neurotransmitters— Certain brain chemicals that may function abnormally in acutely ill bulimic patients.

Obsessive-compulsive disorder (OCD)— A disorder that may accompany bulimia, characterized by the tendency to perform repetitive acts or rituals in order to relieve anxiety.

Purge— To rid the body of food and calories, commonly by vomiting or using laxatives.

Most bulimics find it difficult to stop their behavior without professional help. Many typically recognize that the behavior is not normal, but feel out of control. Some bulimics struggle with other compulsive, risky behaviors such as drug and alcohol abuse. Many also suffer from other psychiatric illnesses, including clinical depression, anxiety, and obsessive-compulsive disorder (OCD).

Most bulimics are females in their teens or early 20s. Males account for only 5-10% of all cases. People of all races develop the disorder, but most of those diagnosed are white.

Bulimic behavior is often carried out in secrecy, accompanied by feelings of guilt or shame. Outwardly, many people with bulimia appear healthy and successful, while inside they have feelings of helplessness and low self-esteem.

Causes and symptoms

Causes

The cause of bulimia is unknown. Researchers believe that it may be caused by a combination of genetic and environmental factors. Bulimia tends to run in families. Research shows that certain brain chemicals, known as neurotransmitters, may function abnormally in acutely ill bulimia patients. Scientists also believe there may be a link between bulimia and other psychiatric problems, such as depression and OCD. Environmental influences include participation in work or sports that emphasize thinness, such as modeling, dancing, or gymnastics. Family pressures also may play a role. One study found that mothers who are extremely concerned about their daughters' physical attractiveness and weight may help to cause bulimia. In addition, girls with eating disorders tend to have fathers and brothers who criticize their weight.

Symptoms

According to the American Anorexia/Bulimia Association, Inc., warning signs of bulimia include:

• eating large amounts of food uncontrollably (bingeing)
• vomiting, abusing laxatives or diuretics, or engaging in fasting, dieting, or vigorous exercise (purging)
• preoccupation with body weight
• using the bathroom frequently after meals

• depression or mood swings
• irregular menstrual periods
• onset of dental problems, swollen cheeks or glands, heartburn or bloating

Diagnosis

Bulimia is treated most successfully when diagnosed early. But because the bulimic may deny there is a problem, getting medical help is often delayed. A complete physical examination in order to rule out other illnesses is the first step to diagnosis.

According to the American Psychiatric Association, a diagnosis of bulimia requires that a person have all of the following symptoms:

• recurrent episodes of binge eating (minimum average of two binge-eating episodes a week for at least three months)
• a feeling of lack of control over eating during the binges
• regular use of one or more of the following to prevent weight gain: self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise
• persistent over-concern with body shape and weight

Treatment

Early treatment is important otherwise bulimia may become chronic, with serious health consequences. A comprehensive treatment plan is called for in order to address the complex interaction of physical and psychological problems in bulimia. A combination of drug and behavioral therapies is commonly used.

Behavioral approaches include individual psychotherapy, group therapy, and family therapy. Cognitive-behavioral therapy, which teaches patients how to change abnormal thoughts and behavior, is also used. Nutrition counseling and self-help groups are often helpful.

Antidepressants commonly used to treat bulimia include desipramine (Norpramin), imipramine (Tofranil), and fluoxetine (Prozac). These medications also may treat any co-existing depression.

In addition to professional treatment, family support plays an important role in helping the bulimic person. Encouragement and caring can provide the support needed to convince the sick person to get help, stay with treatment, or try again after a failure. Family members can help locate resources, such as eating disorder clinics in local hospitals or treatment programs in colleges designed for students.

Alternative treatment

Light therapy—exposure to bright, artificial light—may be useful in reducing bulimic episodes, especially during the dark winter months. Some feel that massage may prove helpful, putting people in touch with the reality of their own bodies and correcting misconceptions of body image. Hypnotherapy may help resolve unconscious issues that contribute to bulimic behavior.

Prognosis

Bulimia may become chronic and lead to serious health problems, including seizures, irregular heartbeat, and thin bones. In rare cases, it may be fatal.

Timely therapy and medication can effectively manage the disorder and help the bulimic look forward to a normal, productive, and fulfilling life.

Prevention

There is no known method to prevent bulimia.

Resources

ORGANIZATIONS

American Anorexia/Bulimia Association, Inc. 293 Central Park West, Suite IR, New York, NY 10024. (212) 501-8351.

Anorexia Nervosa and Related Eating Disorders, Inc. P.O. Box 5102, Eugene, OR 97405. (541) 344-1144.

Center for the Study of Anorexia and Bulimia. 1 W. 91st St., New York, NY 10024. (212) 595-3449.

Eating Disorder Awareness. & Prevention, Inc., 603 Stewart St., Suite 803, Seattle, WA 98101. (206) 382-3587.

National Association of Anorexia Nervosa and Associated Disorders. Box 7, Highland Park, IL 60035. (708) 831-3438.

National Eating Disorders Organization (NEDO). 6655 South Yale Ave, Tulsa, OK 74136. (918) 481-4044.