Bulimia is a serious psychiatric illness, an eating disorder in which the person regularly binge-eats and then tries to compensate for that behavior by over-exercising and purging (by vomiting and/or using laxatives).
Contents of this article:
What is bulimia nervosa?
A person with bulimia nervosa binges on food regularly and feels a loss of control. Binging involves eating large amounts of high-calorie foods over a short period. When the binge starts it is extremely difficult to stop. Some patients say they consume the food so fast that they hardly taste it.
During an episode of binging the individual may consume up to 3,000 calories - in some cases much more.
The binge is followed by a feeling of guilt and shame, which leads to compensatory actions, such as self-induced vomiting, over-exercising, not eating, and overusing diuretics, enemas or laxatives.
According to Boston Children's Hosptial2, 1% to 5% of adolescents and 1.1% to 4.2% of females in the U.S. are believed to have bulimia nervosa.
The National Health Service3, UK, says that up to 8% of females probably have had or will have bulimia nervosa at some time in their lives.
As with anorexia nervosa and other eating disorders, people with bulimia often use their eating behaviors and habits as a means of coping with emotional stress, and typically have an irrational fear of becoming fat, calories and food.
What are the causes of bulimia nervosa?
Scientists and experts are not sure what the exact causes of bulimia nervosa are. They all agree that it is a result of a combination of environmental and genetic factors.
- Genetics - the National Alliance on Mental Illness4 (NAMI) says that individuals with a family history of eating disorders have a higher risk of developing bulimia nervosa.
The American Psychiatric Association5 says that although evidence points to heredity as a contributory factor in eating disorders risk, many people with no prior family history are also afflicted.
- Being bullied - children who have been bullied at school are more likely to develop bulimia compared to other kids.
- Victims of abuse - incidences of bulimia are higher among people who have been sexually and/or physically abused.
- Traumatic/stressful life events - bereavement, divorce, leaving home and other stressful life events are believed to be possible triggers for bulimia nervosa.
- Having mental health problems - bulimia is frequently associated with other psychological problems, such as personality disorders, PTSD (post-traumatic stress disorder), anxiety disorders, OCD (obsessive-compulsive disorder) and depression.
- Cultural factors - some people believe that susceptible individuals, especially young females, who are exposed to Western media photographs of slim and beautiful women become more vulnerable to developing eating disorders. Studies have so far provided conflicting results.
One study found that up to 40% of fashion models may be suffering from an eating disorder.
- Hormones - the onset of eating disorders in most cases coincides with puberty, a period in life when people become more aware of their own bodies and experience major hormonal changes. Several experts suggest that hormonal changes may be linked.
Scientists at the Karolinska Institute in Sweden found that up to 30% of females with bulimia nervosa may be suffering from an imbalance of sex hormones.
- Low self-esteem - after successful treatment many patients say they had had a low opinion of themselves and saw their bulimic behaviors as a way of enhancing their self-worth.
- Competitive sports - in an article in the Asian Journal of Sports Medicine6, Dr. Alan Currie explains that there is strong and consistent evidence that eating disorders are common in sports, especially weight-sensitive ones such as jumping events, endurance sports and esthetic sports. He concluded "In many sports prevention, screening and support programs have been developed for a variety of medical conditions or sports-related injuries. Similar programs should be developed for eating disorders."
Recent developments on bulimia nervosa from MNT news
Eating disorders could start as early as elementary school - Though eating disorders such as anorexia and bulimia are typically associated with teenagers and young adults, researchers caution parents that children between 8 and 12 years old who are difficult eaters could have lurking psychological issues. The team adds that restrictive eating behaviors can surface before puberty.
What are the signs and symptoms of bulimia nervosa?
Although patients with bulimia nervosa diet frequently and over-exercise, unlike anorexia nervosa, some may be slightly underweight, while others can be of normal body weight, overweight and in some cases even obese.
The two major symptoms of bulimia nervosa are binge eating and purging, which create a cycle of guilt:
- Binge eating - this involves eating enormous quantities of high-calorie foods. The patient may not be hungry or need to eat. Initially, it is done as a way of coping with emotional problems, but soon becomes an obsession that the patient is unable to control. This lack of control is felt by the afflicted individual.
The difference between binge eating for a person with bulimia and other people is its frequency. The affected person does it regularly, again and again.
Binging episodes may be planned; the patient goes out shopping and buys specific foods for his or her binge. It may also be spontaneous.
- Purging - at the end of the binge-eating episode the patient feels bloated, unattractive, guilty, ashamed, regretful and full of self-loathing. At the same time there is a powerful and overwhelming fear of gaining weight.
The patient attempts to deal with this fear and other emotional turmoil by purging. Purging is done by self-induced vomiting, taking laxatives, diuretics and/or enemas. They may also diet, go through long periods of fasting, take amphetamines or other illegal substances, and over-exercise.
- A vicious circle of guilt - often triggered by low self-esteem and feeling overweight (while being of normal or near-normal body weight), the patient sets very severe and strict rules regarding eating and/or exercise.
These goals are impossible to maintain. Failure to live up to them results in binging on all the things that were not allowed.
After the binge there are severe feelings of guilt, which is followed by purging and going back to the strict rules...., and the cycle perpetuates.
The following signs and symptoms are also common in patients with bulimia nervosa:
- Body weight keeps changing
- An obsession with eating and food
- Enormous resources (money) devoted to food
- After eating the patient disappears (in most cases to the toilet to vomit)
- Episodes of eating too much
- Periods of strict fasting, may include denial of hunger
- Compulsive exercising
- Scars on the knuckles - medically known as "Russell's Sign". Self-induced vomiting involves forcing your fingers down your throat, when doing this the knuckles rub against your teeth
- Chronic sore/inflamed throat - the acidity of vomit affects the throat
- Unexplained damage to teeth - the acidity of vomit affects the teeth
- Swollen cheeks - due to damage to the parotid glands
- (in females) Irregular menstrual periods
- Broken blood vessels may be seen in the eyes
- Unexpected packages of laxatives, emetics (drugs to induce vomiting), diuretics and diet pills may be found hidden away, or their packaging thrown away in the trash
- Constantly complaining about being overweight
Diagnosing bulimia nervosa
According to the State Government of Victoria7 in Australia, diagnosing bulimia nervosa is not easy. Unlike anorexia nervosa, most patients are not severely underweight. In the majority of cases the individual does everything possible to hide his or her condition. Consequently and unfortunately, that is why the condition may go undiagnosed for a very long time.
If bulimia nervosa is diagnosed early on and the patient receives prompt and proper treatment, outcomes tend to be much better. The American Family Physician8 writes "A good medical history is the most powerful tool."
The patient's first visit is usually to the family doctor (primary care physician, general practitioner, GP).
The primary care physician will probably:
- Ask the patient questions about his or her health
- Ask questions about their emotional health and wellbeing
- Check their medical history
- Find out about their lifestyle
- Carry out a full physical examination
- Order further diagnostic tests to check the patient's health and also rule out other underlying diseases or conditions
If the family doctor suspects the patient has bulimia nervosa, he or she will probably be referred to a mental health expert (a psychiatrist or psychologist).
Diagnostic criteria for bulimia nervosa
The American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders, usually referred to as DSM. The manual says that to be diagnosed with bulimia nervosa, the patient must meet the following criteria:
- Binge eating, which involves consuming an abnormally large amount of food, is done repeatedly. The patient feels unable to control this.
- The excess calories from binging are purged by vomiting, fasting, over-exercising, and misusing laxatives, diuretics, enemas and other drugs.
- Binging and purging have been taking place at least once each week during the last three months. It used to be twice a week, but a DSM-59 update reduced it to once a week.
- The patient's feeling of self-worth is influenced by his/her body shape and weight too much.
- The patient does not have an eating disorder (including anorexia nervosa) with extremely restrictive eating behaviors.
Patients who do not meet all these criteria may still have some kind of eating disorder. Some health care professionals find the DSM criteria too restrictive and say there are patients who lack a criterion but still need help.
What are the treatment options for bulimia nervosa?
Treatment for bulimia nervosa should ideally consist of a combination of psychotherapy, family therapy, nutrition counseling and medication.
Patient participation and acknowledgement that there is a psychological problem are vital if treatment is to be effective. Some patients may resist treatment, while others may have fluctuating levels of cooperation. As treatment is long-term, there is the likelihood that stressful life events may trigger relapses.
The UK National Health Service10 says "The first step towards getting better is to recognise the problem and to have a genuine desire to get well. This may involve a big change in lifestyle and circumstances."
Ideally, treatment should involve:
- The patient
- The patient's family
- A primary care doctor or other health care professional
- A mental health professional
- A dietitian specialized in eating disorders
Treatment usually starts off with psychological therapy; the aim being to help the patient re-establish healthy and realistic attitudes towards food and eating. An individual with bulimia nervosa needs to understand why they have this eating disorder - the feelings, behaviors and thoughts that are contributing to it - and change their attitudes to body weight and food.
Psychotherapy - individual counseling focuses on:
- Cognitive therapy - changing the way the patient thinks.
- Behavioral therapy - changing the way the patient behaves.
The aim is to help the individual learn how to develop realistic and healthy attitudes towards body weight and food, as well as coping with difficult or stressful situations effectively.
Support from family and household members as well as friends is a key component to effective and long-term positive outcomes. The patient's family needs to understand what bulimia nervosa is and to identify its signs and symptoms rapidly. Family therapy has been proven to help patients get better.
Interpersonal therapy concentrates on social roles and relationship. The therapist helps patients evaluate certain areas that cause problems in their life, such as conflicts with friends or family. The aim is to improve these relationships. Interpersonal therapy does not last more than two to four months.
Medications - the only medication specifically approved by U.K. and U.S. regulatory authorities to treat bulimia is fluoxetine (Prozac). Fluoxetine is a type of SSRI (selective serotonin reuptake inhibitor), a drug used for the treatment of depression. Patients with bulimia nervosa who are not depressed may still benefit by taking fluoxetine.
Nutritional counseling - the Harvard Medical School Family Health Guide12 says that nutritional counseling can help the patient break the cycle of binging and compensation, "patients learn to structure and pace meals, and to adjust daily calorie intake to the amount needed to maintain weight."
Hospitalization - an extremely rare treatment for people with bulimia nervosa. Unlike other eating disorders, such as anorexia nervosa, the patient is not usually severely underweight. Doctors may recommend hospitalization if he or she believes there is a risk of suicide or self-harm.
What is the outlook (prognosis)?
The Harvard Medical School Family Health Guide12 says that the short-term response rate for bulimia treatment is "discouragingly low - underscoring the need to be persistent." However, studies that have followed up on bulimia patients over a ten-year period found that 70% got better.
According to the University of Maryland Medical Center13, people with bulimia nervosa commonly relapse after treatment. "They may need long-term care."
What are the possible complications of bulimia nervosa?
Medical complications are common among people with bulimia nervosa, especially if they are not receiving treatment. The University of Rochester Medical Center14 writes "Without treatment, complications persist and can worsen, and can be associated with death."
However, nearly all the complications resolve when patients receive treatment and alter their dysfunctional weight control habits.
The following complications are possible:
- Stomach rupture
- Swollen fingers - caused by regular overuse of laxatives
- Loss of minerals
- Heart failure - due to loss of vital minerals, such as potassium
- Rotting teeth
- Gingivitis - inflammation of the gums
- Inflammation of the esophagus
- Swelling of glands near the cheeks (salivary glands)
- Worsening psychiatric conditions, including anxiety, depression, OCD (obsessive compulsive disorder), and suicidal behavior
- Substance abuse
- Irregular menstruation
- Poor skin and hair, as well as brittle nails
- Chemical imbalance, caused by excessive purging. This can cause tiredness, arrhythmia (abnormal heart rhythms), muscle spasms, convulsions and kidney damage
- Repeated vomiting can cause dehydration which eventually damages the kidneys and increases the risk of kidney stones
- Damage to bowel muscles, leading to chronic constipation
Video - Bulimia nervosa
Professor Janet Treasure explains the complex disorder of bulimia nervosa, how to identify the symptoms, and describes how the eating disorder impacts on a person's life.