What is bulimia nervosa
People with bulimia nervosa or bulimia have recurrent and frequent episodes of eating unusually large amounts of food (binge eating or eat to excess) and feel a lack of control over these episodes. This binge eating is followed by behavior that compensates for the overeating in extreme ways, such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors – to prevent weight gain. Over time, these steps can be dangerous — both physically and emotionally. They can also lead to compulsive behaviors (ones that are hard to stop).
To have bulimia, a person must be binging and purging regularly, at least once a week for a couple of months. Binge eating is different from going to a party and “pigging out” on pizza, then deciding to go to the gym the next day and eat more healthfully
People with bulimia eat a large amount of food (often junk food) at once, usually in secret. Sometimes they eat food that is not cooked or might be still frozen, or retrieve food from the trash. They typically feel powerless to stop the eating and can only stop once they’re too full to eat any more or they may have to go to extreme measures (like pouring salt all over a dessert to make it inedible) in order to get themselves to stop eating. Most people with bulimia then purge by vomiting, but also may use laxatives or excessive exercise.
Diagnostic criteria for bulimia nervosa include the following 1):
- Recurrent binge-eating in which a binge is defined as consuming a very large amount of food in a discrete period of time, such as within 2 hours, and a sense of loss of control over eating during that episode;
- Recurrent compensatory behavior, such as vomiting, fasting, exercise, laxative use, diuretic use, diet pill use; and
- Self-evaluation unduly influenced by weight and body shape.
The binge-eating and compensatory behaviors both occur, on average, at least once a week for 3 months, and do not occur exclusively during anorexia nervosa 2). The severity of bulimia nervosa, mild to extreme, is based on the frequency of compensatory behaviors. Compensatory behaviors distinguish bulimia nervosa from binge eating disorder. Patients with bulimia nervosa are often within a normal or high normal weight range for age, gender, and height.
Bulimia nervosa is delineated into 2 distinct subtypes:
- Purging and
With the purging subtype, patients engage in some method to remove the binged food from their bodies. This is most often accomplished by self-induced vomiting but can include the misuse of laxatives, enemas, or diuretics. Nonpurging bulimics use fasting or excessive exercise as the primary compensation for binges but do not regularly purge. Regardless of subtype, bulimic patients have negative self-evaluations, placing inappropriate importance on weight and body image.
Secrecy, shame, and guilt tend to accompany bulimia nervosa in adolescents, and in turn these emotions may negatively affect the age-appropriate development of adolescents by interfering with social and interpersonal processes 3). Males with bulimia nervosa appear to be more likely than females to present with overexercise and steroid use 4). Risk for bulimia nervosa is increased in males who participate in sports such as wrestling, gymnastics, diving, and long-distance running, in which weight and appearance can affect performance 5). There is also a limited database suggesting that homosexual males may be more at risk than their heterosexual peers for the development of bulimia nervosa 6).
There are challenges in diagnosing bulimia nervosa in childhood and adolescence because of developmental differences between younger patients and adults. Data suggest that loss of control may be a more valid marker than calories consumed in terms of determining whether an eating episode should be characterized as binge eating 7). Binge eating may also occur less frequently in younger patients because children do not have access to, or control over, foods in the same way as adults with bulimia nervosa 8). Similar limitations on abstract thinking, self-expression, and minimization as described for adolescent anorexia nervosa are relevant for adolescent bulimia nervosa as well; thus, parental interviews and other collateral reports may be essential to obtain an accurate history 9).
The short-term course of bulimia nervosa is marked by fluctuating symptoms with varying cycles of remission and exacerbation. Typically individuals with bulimia nervosa have exhibited symptoms for nearly 5 years before seeking treatment 10). Outcome in bulimia nervosa is highly variable. Of those with bulimia nervosa who receive treatment, 50% are symptom free 5 to 10 years later, whereas the other 50% continue to exhibit eating disorder symptoms. One long-term follow-up study suggests, however, that the number of women who continue to meet full criteria for bulimia nervosa declines as the duration of follow-up increases 11). A history of low self-esteem, childhood obesity, and personality disorders predict a longer duration of illness 12). Self-injury, substance abuse, and other impulsive and risk-taking behaviors are common in adults and older teens seeking treatment, but appear to be less common in younger adolescents with bulimia nervosa 13).
Anorexia nervosa vs bulimia nervosa
Although anorexia nervosa and bulimia nervosa are very similar, people with anorexia are usually very thin and underweight, but those with bulimia may be an average weight or can be overweight.
Bulimia nervosa statistics
The incidence of bulimia nervosa is increasing in urbanized areas and countries undergoing rapid Westernization 14). Between 1% and 2% of adolescent females but can be as high as 10% in vulnerable populations, such as college-aged women 15) and 0.5% of adolescent males are estimated to meet the Diagnostic and Statistical Manual for Mental Disorders-IV criteria for bulimia nervosa 16). The estimated male-to-female ratio is 1:10, although some estimates are as high as 1:3 17). Bulimia nervosa occurs in 2.3% of white women but in only 0.40% of black women 18). Bulimia nervosa typically begins in adolescence between 14 and 22 years of age 19) and for some individuals, arises after an episode of anorexia nervosa. Demographically, most patients with bulimia nervosa are single, college educated, and in their mid-20s. Bulimia nervosa is rarely diagnosed in children and young adolescents, although older patients presenting for treatment often pinpoint the onset of their illness to early adolescence 20).
Bulimia nervosa causes
The exact cause of bulimia is unknown. The cause of bulimia nervosa is multifactorial, including biological, psychological, family, society or cultural factors. Many more women than men have bulimia. The disorder is most common in teenage girls and young women. The person usually knows that her eating pattern is abnormal. She may feel fear or guilt with the binge-purge episodes.
Bulimia nervosa occurs more often in first-degree relatives of those with eating disorders than in the general population 21). Twin studies show a higher concordance rate in monozygotic twins than in dizygotic twins, with heritability threshold estimates ranging from 60% to 83% 22). Family factors, abuse, post traumatic stress disorder (PTSD), impulsive personality traits, and perfectionistic temperament have also been suggested to be risk factors for bulimia nervosa 23). In addition, social pressures to be thin, body dissatisfaction, dieting, and negative affect are associated with the development of bulimia nervosa 24). Dieting to try to accomplish a thin ideal physique is thought to lead to physical and psychological starvation 25). Physiological starvation then leads to hunger and promotes binge eating when food becomes available. Guilt associated with binge eating and fear of weight gain lead to purging behavior and increased dieting. Thus, a cycle of deprivation, binge eating, and purging is established.
Bulimia nervosa symptoms
Unlike anorexia nervosa, people with bulimia nervosa usually maintain what is considered a healthy or normal weight, while some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight and are intensely unhappy with their body size and shape. With bulimia, eating binges may occur as often as several times a day for many months. The person often eats large amounts of high-calorie foods, usually in secret because it is often accompanied by feelings of disgust or shame. During these episodes, the person feels a lack of control over the eating. The binge eating and purging cycle can happen anywhere from several times a week to many times a day.
Binges lead to self-disgust, which causes purging to prevent weight gain. Purging may include:
- Forcing oneself to vomit
- Excessive exercise
- Using laxatives, enemas, or diuretics (water pills)
Purging often brings a sense of relief.
- People with bulimia are often at a normal weight, but they may see themselves as being overweight. Because the person’s weight is often normal, other people may not notice this eating disorder.
Symptoms that other people can see include:
- Spending a lot of time exercising
- Suddenly eating large amounts of food or buying large amounts of food that disappear right away
- Regularly going to the bathroom right after meals
- Throwing away packages of laxatives, diet pills, emetics (drugs that cause vomiting), or diuretics
- Calluses on middle phalanges from using fingers to induce vomiting (Russell’s sign)
Other symptoms include:
- Chronically inflamed and sore throat
- Swollen salivary glands in the neck and jaw area (sialadenosis), a noninflammatory enlargement of the salivary glands 26).
- Worn tooth enamel, and increasingly sensitive and decaying teeth as a result of exposure to stomach acid
- Acid reflux disorder and other gastrointestinal problems
- Intestinal distress and irritation from laxative abuse
- Severe dehydration from purging of fluids
- Electrolyte imbalance—too low or too high levels of sodium, calcium, potassium, and other minerals that can lead to a heart attack or stroke.
Psychiatric comorbidity associated with bulimia nervosa
Bulimic patients are characterized as extroverted perfectionists who are self-critical, impulsive, and emotionally undercontrolled 27). High prevalence rates of any affective disorder (75%), major depressive disorder (63%), and anxiety disorders (36%) have been reported 28). The majority of patients report that the initial presentation of the depression or anxiety disorder occurred prior to the presentation of bulimic symptoms 29).
Substance abuse is an additional common comorbidity. The National Center on Addiction and Substance Abuse at Columbia University reported that 30% to 70% of bulimics have a substance abuse problem 30). Substances of abuse include tobacco, alcohol, and prescription and over-the-counter medications, such as diet pills and stimulants. Alcoholism has been reported to affect 31% of bulimics and is often found with major depressive disorder and posttraumatic stress disorder 31). Strong familial relationships have also been observed between bulimia nervosa and alcoholism 32).
A controlled community sample study compared women with bulimia nervosa with normal controls and controls with other psychiatric disorders. Although current alcoholism was similar among the groups, bulimics had higher rates of deliberate self-harm than both control groups and more illicit drug use than the normal controls 33).
Self-injury is a concern for patients with bulimia nervosa. In one study, 34% of bulimic patients reported having injured themselves at sometime in their lives, and 21.3% reported having injured themselves in the last 5 months 34). Patients most often injure themselves by cutting or scratching their arms, hands, legs, or face, and many of these injuries result in bleeding and scarring. Patients with borderline personality disorder who injure themselves are more likely to also suffer from bulimia nervosa than are those who do not injure themselves. Comorbid diagnoses of bulimia nervosa and borderline personality disorder have been shown to increase risk of frequent self-mutilation, which may influence rates of attempted and completed suicide in these patients 35).
Bulimic patients are more likely to have experienced parental alcoholism, low parental contact, and high parental expectations 36). Although the core symptoms of this disorder are disturbed eating habits and self-perception, the significant comorbidities complicate the identification and treatment of bulimia nervosa.
Bulimia nervosa treatment
Most patients with bulimia nervosa do not require hospitalization, and the preferred method of treatment is outpatient-based 37). Cognitive-behavioral therapy (CBT) is the standard and preferred psychological method of treatment for these patients. In multiple studies, cognitive-behavioral therapy (CBT) has been demonstrated superior to other forms of psychological treatment, such as interpersonal psychotherapy 38). This method of treatment for bulimia nervosa was first described by Fairburn in 1981 39) and has 2 goals: (1) to stop the vicious circle of overeating and vomiting and (2) to modify the abnormal attitudes toward food.
The Cognitive-behavioral therapy (CBT) method has 3 phases that overlap in a 20-week course of therapy 40). During the first phase, patients are taught about bulimia nervosa and actions that perpetuate the disease. The patient keeps detailed food records, including the frequency of bingeing or purging, which are used in therapy sessions. The second phase consists of teaching the patient to broaden food choices, and additional time is spent on correcting dysfunctional food and body thoughts. The final 3 therapy sessions comprise the third stage and focus on maintenance and relapse prevention. Upon completion of cognitive-behavioral therapy, 45% of patients stopped bingeing and purging and 35% no longer met diagnostic criteria for bulimia nervosa 41).
Relapse primarily occurs during the first 4 months after cognitive-behavioral therapy and affects 31% to 44% of patients 42). Relapse has been attributed to low motivation during treatment and overly ritualized eating and high frequency of vomiting before treatment 43). Rapid and sustained response to cognitive-behavioral therapy has been found to be dependent upon frequency of bingeing before treatment and a self-directed personality 44).
Pharmacologic treatment may be a primary or adjunct therapy for bulimia nervosa. Fluoxetine has been shown to be effective in the treatment of bulimia nervosa. One 16-week and 2 double-blind 8-week clinical trials conducted in the early to mid-1990s all found fluoxetine, 60 mg/day, to significantly decrease overall binge eating and vomiting 45). Fluoxetine also has been reported to significantly decrease vomiting and binge eating in as little as 4 weeks of therapy 46). Bulimic patients followed for up to 1 year on fluoxetine therapy were found to have a significantly decreased likelihood of relapse and improved overall outcome when compared with placebo 47). A case series of 5 underweight patients with binge-eating and purging reported sertraline to be effective in weight restoration and reduction of core eating disorder behaviors 48). Although citalopram 49) was effective in treating binge-eating disorder, no differences were noted between cases and controls for fluvoxamine 50). Milnacipran, an antidepressant with both serotonergic and noradrenergic function, was effective for the reduction of bulimic symptoms in an uncontrolled case series 51). To date, fluoxetine remains the only medication approved by the U.S. Food and Drug Administration for the treatment of bulimia nervosa.
The combination of CBT with fluoxetine therapy has been shown to be superior to medication or CBT alone 52). Frequency and severity of vomiting and binge eating were decreased in patients on both therapies. Also, in a recent study, patients reported better social adjustment up to 10 years after receiving CBT, fluoxetine, or both therapies for treatment of bulimia nervosa compared with that of women who had been randomized to placebo 53). For bulimic patients who do not respond to CBT, fluoxetine has been shown to be effective in decreasing bulimic features 54). In light of this research, the current treatment for bulimia nervosa consists of outpatient-based CBT and fluoxetine therapy.
Generally, treatment of physical symptoms is dependent upon severity of the problem (e.g., hypokalemia) and whether or not reversal is expected at cessation of purging behaviors (e.g., dysphagia).
Primary care physicians should consider referring patients for specialty care in situations where eating disorder symptoms are persistent, comorbid psychopathology is present, or self-injurious behaviors or suicidal ideation is encountered. Specialty clinics directed at the care of patients with eating disorders may be most beneficial 55).
People with bulimia rarely have to go to the hospital, unless they:
- Have anorexia nervosa
- Have major depression
- Need medicines to help them stop purging
Most often, a stepped approach is used to treat bulimia. Treatment depends on how severe the bulimia is, and the person’s response to treatments:
- Support groups may be helpful for mild bulimia without other health problems.
- Counseling, such as talk therapy and nutritional therapy are the first treatments for bulimia that does not respond to support groups.
- Medicines that also treat depression, known as selective serotonin-reuptake inhibitors (SSRIs) are often used for bulimia. Combining talk therapy with SSRIs may help, if talk therapy alone does not work.
People may drop out of programs if they have unrealistic hopes of being “cured” by therapy alone. Before a program begins, people should know that:
- Different therapies will likely be needed to manage this disorder.
- It is common for bulimia to return (relapse), and this is no cause for despair.
- The process is painful, and the person and their family will need to work hard.
The stress of illness can be eased by joining a support group. Sharing with others who have common experiences and problems can help you not feel alone.
Outlook (Prognosis) for Bulimia
Bulimia is a long-term illness. Many people will still have some symptoms, even with treatment.
People with fewer medical complications of bulimia and those willing and able to take part in therapy have a better chance of recovery.
Although bulimia nervosa is more common than anorexia nervosa, the mortality rate is lower and the recovery rate higher than that of anorexia nervosa 56). Mortality from bulimia nervosa is approximated at 0% to 3% but may be underestimated due to few long-term follow-up studies involving bulimic patients. Approximately 50% of patients are free from all bulimic symptoms 5 years after treatment 57). Although outcomes research on bulimia nervosa is sparse, with limited statistical estimates, it has been shown that mortality and recovery are directly related to early intervention and treatment 58).
Patients who suffer from anorexia nervosa and exhibit bulimic features have more difficulty reaching normal body weight and tend to be at lower body weights, even after treatment 59). Anorexics are also prone to developing binge eating after treatment for anorexia nervosa. A 1997 study reported that 30% of treated anorexics developed binge-eating behavior up to 5 years post hospitalization 60). When assessing a normal or overweight patient with bulimia nervosa, it is important to gather historical information about the presence and duration of past anorexia nervosa. Anorexia nervosa complicated by bulimic symptoms is associated with higher mortality rates than those from bulimia nervosa alone 61). However, mortality rates and comorbidity rates for all eating disorders may be overestimated due to the fact that most studies take place in academic or specialty research settings. These patients are often more severely ill than patients in outpatient, community-based settings. The actual recovery rates for eating disorders are probably greater, and the overall outcome picture not so bleak 62).
Possible Complications of Bulimia
Bulimia can be dangerous. It may lead to serious health problems over time. For example, vomiting over and over can cause:
- Stomach acid in the esophagus (the tube that moves food from the mouth to the stomach). This can lead to permanent damage of this area.
- Tears in the esophagus or Mallory-Weiss tears from excessive vomiting
- Dental cavities
- Swelling of the throat
Vomiting and overuse of enemas or laxatives can lead to:
- Your body not having as much water and fluid as it should
- Low level of potassium in the blood, which may lead to dangerous heart rhythm problems
- Hard stools or constipation
- Rectal prolapse 63)
- Damage of the pancreas
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