Bulimia Nervosa

Bulimia nervosa is a serious eating disorder marked by a destructive pattern of binge-eating and recurrent inappropriate compensatory behaviors to control one’s weight. It can occur together with other psychiatric disorders such as depression, obsessive-compulsive disorder, substance dependence, or self-injurious behavior. Bulimia nervosa is an invisible eating disorder, because patients are of normal weight or overweight. Binge eating is the rapid consumption of an unusually large amount of food in a short period of time. Unlike simple overeating, the hallmark feature of a binge is feeling out of control. This means that one cannot stop the urge to binge once it has begun or that one has difficulty ending the eating episode even when far past being full. “Inappropriate compensatory behavior” to control one’s weight may include purging behaviors (such as self-induced vomiting, abuse of laxatives, diuretics, or enemas) or non-purging behaviors (such as fasting or excessive exercise). Some people who have placed strict restrictions on what and when it is OK to eat might feel like they have binged after only a small amount of food (like a cookie). Since this is not an objectively large amount of food by social comparison, it is called a subjective binge.

There are two types of bulimia nervosa. In the purging type, the person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. In the nonpurging type, the individual uses fasting or excessive exercise to control weight, but does not regularly purge.

People with bulimia nervosa often feel a lack of control during their eating binges. Food is often eaten secretly and rapidly. A binge is usually ended by abdominal discomfort, social interruption, or running out of food. When the binge is over, the person with bulimia often feels guilty and purges to rid his or her body of the excess calories. To be diagnosed with bulimia nervosa, a person must have had, on average, a minimum of two binge-eating episodes a week for at least three months. However any amount of binge eating and purging is unhealthy and is worthy of an evaluation.

Who develops bulimia?

The typical age of onset for bulimia nervosa is late adolescence or early adulthood, but onset can and does occur at any time throughout the lifespan. Bulimia nervosa typically begins in adolescence or early adulthood although it can strike at any age. Like anorexia nervosa, bulimia nervosa mainly affects females. Ten percent to 15 percent of affected individuals are male although this may be an underestimate. An estimated two percent to three percent of young women develop bulimia nervosa, compared with the one-half to one percent that is estimated to suffer from anorexia. Bulimia strikes across racial and ethnic groups and across the socioeconomic spectrum. Studies indicate that about 50 percent of those who have anorexia nervosa later develop bulimia nervosa.

How do people with bulimia control their weight?

People with bulimia nervosa are overly concerned with body shape and weight. They make repeated attempts to control their weight by fasting and dieting, vomiting, using drugs to stimulate bowel movements and urination, and exercising excessively. Weight fluctuations are common because of alternating binges and fasts. Unlike people with anorexia, people with bulimia are usually within a normal weight range. However, many heavy people who lose weight begin vomiting to maintain the weight loss. Laxatives are dangerous and ineffective weight control measures. Laxatives work in the part of the intestine after the food has already been absorbed. They do not help you shed calories, only water and valuable electrolytes (like potassium and sodium).

What are the common signs of bulimia nervosa?

Constant concern about food and weight is a primary sign of bulimia. Common indicators of self-induced vomiting are the erosion of dental enamel (due to the acid in the vomit) and scarring on the backs of the hands (due to repeatedly pushing fingers down the throat to induce vomiting).

A small percentage of people with bulimia show swelling of the glands near the cheeks called parotid glands. People with bulimia may also experience irregular menstrual periods and a decrease in sexual interest. A depressed mood is also commonly observed as are frequent complaints of sore throats and abdominal pain. Despite these telltale signs, bulimia nervosa is difficult to catch early. Binge eating and purging are often done in secret and can be easily concealed by a normal-weight person who is ashamed of his or her behavior. Characteristically, these individuals have many rules about food — e.g. good foods, bad foods — and can be entrenched in these rules and particular thinking patterns. This preoccupation and these behaviors allow the person to shift their focus from painful feelings and reduce tension and anxiety perpetuating the need for these behaviors.

Are there any serious medical complications?

Persons with bulimia — even those of normal weight — can severely damage their bodies by frequent binging and purging. Electrolyte imbalance and dehydration can occur and may cause cardiac complications and, occasionally, sudden death. In rare instances, binge eating can cause the stomach to rupture, and purging can result in heart failure due to the loss of vital minerals like potassium.

Do we know what causes bulimia nervosa?

Although the precise causes of bulimia nervosa are unknown, we do know that it is caused by a combination of genetic and environmental factors. Ongoing research is poised to identify specific genes that might influence risk for the development of bulimia nervosa. Scientists have studied the role of personality, genetics, environment, and biochemistry of people with these illnesses. There is some evidence that obesity in adolescence or familial tendency toward obesity predisposes an individual to the development of the disorder. Some individuals with bulimia report feeling a “kind of high” when they vomit. People with bulimia are often impulsive and may also abuse alcohol, drugs, and engage in self-injurious behavior. Eating disorders like anorexia and bulimia tend to run in families, and girls are most susceptible. Recently, scientists have found certain neurotransmitters (serotonin and norepinephrine) to be altered in some persons with bulimia nervosa. We do not yet know whether these differences exist before bulimia develops or are a consequence of having the illness. Most likely, it is a combination of environmental and biological factors that contribute to the development and expression of this disorder. People with bulimia nervosa often say that binge eating and purging provide temporary relief from tension although after the binge and purge, negative feelings can be increased by the guilt and disgust over the behaviors they have engaged in.

Is treatment available for persons with bulimia nervosa?

Most people with bulimia can be treated through individual outpatient therapy because they aren’t in danger of starving themselves as are persons with anorexia nervosa. However, if the binge purge cycle is out of control, admission to an eating disorders treatment program may help the individual interrupt their cycle to give them a head start on getting their symptoms under control.

Cognitive-behavioral therapy (CBT), either in a group setting or individual therapy session, the treatment of choice for bulimia nervosa can lead to complete abstinence from binge eating and purging in around 40% of patients. CBT focuses on self-monitoring of eating and purging behaviors as well as changing the distorted thinking patterns associated with the disorder. Cognitive-behavioral therapy is often combined with nutritional counseling. The only FDA approved medication for bulimia nervosa is fluoxetine (Prozac) showing 50-60% reduction in median binge eating and purging in the short term, although these behaviors often return when the drug is discontinued.  It is good to remember that many psychiatric medications can impact weight and it is important to review with a doctor before starting any medication.  Do not stop taking medication without consulting a doctor for the risks and benefits.

Group therapy is especially effective for college-aged and young adult women because of the understanding of the group members. In group therapy they can talk with peers who have similar experiences. Additionally, support groups can be helpful as they can be attended for as long as necessary, have flexible schedules, and generally have no charge. Support groups, however, do not take the place of treatment. Sometimes a person with an eating disorder is unable to benefit from group therapy or support groups without the encouragement of a personal therapist.

Treatment plans should be adjusted to meet the needs of the individual concerned, but usually a comprehensive treatment plan involving a variety of experts and approaches is best. It is important to take an approach that involves developing support for the person with an eating disorder from the family environment or within the patient’s community environment (support groups or other socially supportive environments).

What about prevention?

Prevention research is increasing as scientists study the known “risk factors” for these disorders. Given that bulimia and other eating disorders are multi-determined and affect young women, there is preliminary information on the role and extent such factors as self esteem, resilience, family interactions, peer pressure, the media and dieting might play in its development. Advocacy groups are also engaged in prevention through efforts such as removing damaging articles from teen magazines on dieting and the importance of being thin and destructive web-sites that promote anorexia nervosa (pro-ana) and bulimia nervosa (pro-mia) as a lifestyle rather than a debilitating disorder.