Bulimia nervosa - non-technical article
Bulimia nervosa is a potentially life-threatening 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.
Bulimia nervosa is primarily a disorder of industrialized countries where food is abundant and the culture values a thin appearance. In Westernized countries, 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 ismore often diagnosed in homosexuals than in heterosexuals. Some experts believe that the 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.
Bulimia is an eating disorder whose main feature is eating an unreasonably large amount of food in a short time and then following this binge by purging the body of calories. Purging most often is done by selfinduced 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. Nonpurging bulimia is sometimes called exercise bulimia. Bulimia nervosa is officially recognized as a psychiatric disorder in the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) published by the American Psychiatric Association.
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 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 normalsized portion of food. Some studies have shown that up to 60% of people with bulimia have a history of 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.
Dieting usually is the trigger that starts a person down the road to bulimia. The cycle might being with a person going on a rigorous low-calorie diet. Unable to stick with the unrealistic diet, he or she then overeats, feels guilty about overeating, and then exercises 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.
Competitive athletes have an increased risk of developing bulimia nervosa, especially in sports where weight is 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.
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 some catalyst then triggers the behavior, which then becomes self-reinforcing.
- Hereditary, biological, psychological and social factors all appear to play a role. 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 with 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 that often occur with bulimia such as depression. 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 often involved in risky behaviors such as shoplifting, drug or alcohol abuse, and risky sexual activities. People with bulimia might have lowself 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 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 mediamessage that thin is ‘‘good’’ and fat is ‘‘bad.’’
Signs and symptoms
People with bulimia are very good at hiding their behavior, and weight, heart rate, and blood pressure may all be normal. However, 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
- sores or calluses on knuckles or hands from using them to induce vomiting
- electrolyte imbalances revealed by laboratory tests
- dry skin
- irregular or absent menstrual cycles in women
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 overexercising.
Several different evaluations can be used to examine a person’s mental state. Psychiatric assessment 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 (EAT), and the Kids’ Eating Disorder Survey (KEDS).
Once all information has been compiled, 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.
- Bingeing and purging does not occur exclusively during periods of anorexia nervosa.
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 (estimated to occur in 40%–70% of people with bulimia), dysthemic 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. 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 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 special and 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.
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 nervosa 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.
Other drugs are being explored for use in the treatment of bulimia.
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 to 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.
Nutrition and diet counseling
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.
The following dietary changes may be helpful for bulimic individuals:
- Eating small but nutritious meals at regularly scheduled hours.
- Avoiding sweet, baked goods or any other foods that may cause craving.
- Avoiding allergenic foods.
- Limiting intake of alcohol, caffeine, monosodium glutamate (MSG), and salty foods.
Alternative and complementary therapies
The following supplements may help improve bulimic symptoms and prevent deficiency of essential vitamins and minerals: Multivitamin and mineral supplement to prevent deficiency of essential nutrients. Vitamin B complex with C. Zinc supplement. Bulimic patients may have zinc deficiency, and zinc is an important mineral needed by the body for normal hormonal activity and enzymatic function.
A homeopathic physician may prescribe patient-specific remedies for the treatment of bulimia.
Light therapy. Exposure to artificial light, available through full spectrum light bulbs or specially designed ‘‘light boxes,’’ may be useful in reducing bulimic episodes, especially during the dark winter months.
Hypnotherapy may help resolve unconscious issues that contribute to bulimic behavior.
Yoga, qigong, t’ai chi, or dance not only make patients physically healthier but can also make them feel better about themselves.
Other potentially beneficial treatments for bulimia include Chinese herbal therapy, hydrotherapy and biofeedback training.
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.
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 Web sites.
- 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 and keeping therapy appointments
- monitoring negative self-talk and practicing positive self-talk
- spending time doing something enjoyable every day
- getting at least seven hours of sleep each night
- spending time with friends or family
Carleton, Pamela and Deborah Ashin. Take Charge of Your Child’s Eating Disorder: A Physician’s Step-By-Step Guide to Defeating Anorexia and Bulimia. New York: Marlowe & Co., 2007.
Fairburn, Christopher. Overcoming Binge Eating, Second Edition: The Proven Program to Learn Why You Binge and How You Can Stop. Guilford Press; 2nd edition (9 Aug 2013).
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Kolodny, Nancy J. The Beginner’s Guide to Eating Disorders Recovery. Carlsbad, 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 Recovery. Oakland, CA: New Harbinger, 2004.
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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 again.
Serotonin—5-Hydroxytryptamine; a substance that occurs throughout the body with numerous effects including neurotransmission. Inadequate amounts of serotonin are implicated in some forms of depression and obsessive-compulsive disorder.