Bulimia nervosa: Description:
Also called as Bulimia Nervosa.
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.
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 over-exercising 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 nervosa 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.
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 nervosa 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.
Patients with bulimia nervosa 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.
Symptoms of bulimia nervosa:
People with bulimia nervosa nearly always practice it in secret, and, although they may be underweight, they are not always anorexic. Symptoms or signs of bulimia may, therefore, be very subtle and go unnoticed. They may include:
Causes and Risk factors:
There is no single cause for eating disorders. Although concerns about weight and body shape play a role in all eating disorders, the actual cause of these disorders appear to result from many factors, including cultural and family pressures and emotional and personality disorders. Genetics and biologic factors may also play a role.
Genetic: Two recently published reviews (in 1999 and 2000) suggest that there is some heritability for bulimia nervosa. 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 nervosa 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 nervosa. Some of these theories maintain that:
- Regularly going to the bathroom right after meals.
- Suddenly eating large amounts of food or buying large quantities that disappear right away.
- Compulsive exercising.
- Broken blood vessels in the eyes (from the strain of vomiting).
- Pouch-like appearance to the corners of the mouth due to swollen salivary glands (occurs within days of vomiting in about 8% of people with bulimia).
- Dry mouth.
- Tooth cavities, diseased gums, and irreversible enamel erosion from excessive acid.
- Rashes and pimples Small cuts and calluses across the tops of finger joints due to self-induced vomiting.
The first step towards a diagnosis is to admit the existence of an eating disorder. Often, the patient needs to be compelled by a parent or others to see a doctor because the patient may deny and resist the problem. Some patients may even self-diagnose their condition as an allergy to carbohydrates, because after being on a restricted diet, eating carbohydrates can produce gastrointestinal problems, dizziness, weakness, and palpitations. This may lead such people to restrict carbohydrates even more severely.
It is often extremely difficult for parents as well as the patient to admit that a problem is present. For example, because food is such an intrinsic part of the mother-child relationship, a child's eating disorder might seem like a terrible parental failure. Parents may have their own emotional issues with weight gain and loss and perceive no problem with having a "thin" child.
It is recommended that a supportive companion be present during part of the initial medical interview to offer additional information on the patient's eating history and to help offset any resistance or denial the patient may express.
Various questionnaires are available for assessing patients. The Eating Disorders Examination (EDE), which is an interview of the patient by the doctor, and the self-reported Eating Disorders Examination-Questionnaire (EDE-Q) are both considered valid tests for assessing eating disorder diagnosis and determining specific features of the individuals condition (such as vomiting or laxative use).
Another test is called the SCOFF questionnaire. It is proving to be very reliable in accurately identifying both very young and adult patients who meet the full criteria for anorexia or bulimia nervosa. (It may not be as accurate in people who do not meet the full criteria.)
In spite of the prevalence of bulimia bulimia nervosa, in one study only 30% of Midwest family doctors had ever diagnosed bulimia in a patient. Younger and female doctors are more likely to detect bulimia. A doctor should make a diagnosis of bulimia if there are at least two bulimic episodes per week for 3 months. Because people with bulimia tend to have complications with their teeth and gums, dentists could play a crucial role in identifying and diagnosing bulimia.
Once a diagnosis is made, doctors should immediately check for any serious complications of starvation. They should also rule out other medical disorders that might be causing the anorexia. Tests should 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 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.
- A complete blood count.
- Tests for electrolyte imbalances (low potassium levels mean the disorder is more likely to be accompanied by the binge-purge syndrome).
- Test for protein levels.
- An electrocardiogram and a chest x-ray.
- Tests for liver, kidney, and thyroid problems.
- A bone density test.
Some experts recommend a stepped approach for patients with bulimia, which follow specific stages depending on the severity and response to initial treatments:
Support groups: This is the least expensive approach and may be helpful for patients who have mild conditions with no health consequences.
Cognitive-behavioral therapy (CBT): Along with nutritional therapy is the preferred first treatment for bulimia that does not respond to support groups.
Drugs: The drugs used for bulimia are typically antidepressants known as selective serotonin-reuptake inhibitors (SSRIs). A combination of CBT and SSRIs is very effective if CBT is not helpful.
Patients with bulimia rarely need hospitalization except under the following circumstances:
- Binge-purge cycles have led to anorexia.
- Drugs are needed for withdrawal from purging Major depression is present.
Psychologic Therapy: Cognitive-behavioral therapy (CBT) is the first-line of therapy for most patients with bulimia and is successful in about 60% of cases. In one study of bulimic patients, those who did not respond to CBT tended to be less committed to the treatment, were more preoccupied with their symptoms, and had ritualized eating behaviors. Interpersonal therapy may be tried if CBT fails, although in one study it was no more successful than antidepressants.
Antidepressants: Because of the high incidence of depression in patients with bulimia, antidepressant medication is often recommended for patients who have normal weight or for those who are overweight. They should be used in combination with CBT. (Some of these drugs can cause weight loss and should not be used in patients who are underweight.)
The most common antidepressants prescribed for bulimia are selective serotonin reuptake inhibitors (SSRIs) such as:
- Fluoxetine (Prozac).
- Sertraline (Zoloft).
- Paroxetine (Paxil).
- Fluvoxamine (Luvox).
Studies are mixed, however, on whether SSRIs offer an additional advantage in reducing binge-eating compared to CBT. Prozac has been approved for bulimia and is considered the drug of choice, although some studies suggest that other SSRIs, such as Luvox, may be even more effective.
Other Drug Therapy for Bulimia Nervosa
Drugs to Prevent Vomiting: In one study, ondansetron (Zofran), a drug that prevents vomiting, reduced the binge-purge episodes by half. The drug may cause depression in people already on SSRI antidepressants. More studies are needed.
Sibutramine: Sibutramine (Meridia) is a drug used for weight loss. It does so by balancing two important brain chemicals, serotonin and norepinephrine, which helps to increase metabolism. Some evidence suggests that the actions of this drug may be useful for people who binge. However, this drug should be used only for patients with bulimia who have normal or above normal weight, and should never be used for those who are anorexic.
Inositol: Inositol is a B vitamin that is being investigated for bipolar disorder, anxiety, and depression. A 2001 study suggests that it may also have benefits for bulimic patients.
Topiramate: The antiepileptic drug topiramate (Topamax) has been shown in studies to reduce bingeing and purging episodes in bulimics, as well as to improve self-esteem, attitudes, and body image.
Alternative Approaches to Bulimia
Hypnosis: A study on women with bulimia showed that they had a high susceptibility to hypnosis, suggesting that it might be beneficial as part of their treatment. People with anorexia, on the other hand, seem to be very resistant to the state of vulnerability required in this process.
Light Therapy: Some researchers have noted an association between bulimia and seasonal affective disorder (depression that intensifies in the darker winter months). This suggests that therapy using intense directed light may be useful. Studies report, however, that while light therapy relieves depression, it has little effect on binge-purging behavior. Some experts suggest it may be more useful in combination with medication and psychotherapy.
Guided Imagery: A technique called guided imagery reduced frequency of binges and vomiting by almost 75% in one study. This method uses audiotapes to evoke images that will reduce stress and help achieve specific goals.
Eating disorders are nearly always treated with some form of psychiatric or psychologic treatment. Depending on the problem, different psychologic approaches may work better than others.
Cognitive-Behavioral Therapy: Cognitive-behavioral therapy (CBT) works on the principle that a pattern of false thinking and belief about one's body can be recognized objectively and altered, thereby changing the response and eliminating the unhealthy reaction to food. One approach for bulimia is the following:
- Over a period of 4 - 6 months the patient builds up to eating 3 meals a day, including foods that the patient has previously avoided.
- During this period, the patient monitors and records the daily dietary intake along with any habitual unhealthy reactions and negative thoughts toward eating while they are occurring.
- The patient also records any relapses (binges or purging). Such lapses are reported objectively and without self-criticism and judgment.
- The patient discusses the responses with a cognitive therapist at regular sessions. Eventually the patient is able to discover the false attitudes about body image and the unattainable perfectionism that underlies the opposition to food and health.
- Once these habits are recognized, food choices are broadened, and the patient begins to challenge any entrenched and automatic ideas and responses. The patient then replaces them with a set of realistic beliefs along with actions based on reasonable self-expectations.
Interpersonal therapy deals with depression or anxiety that might underlie the eating disorders along with social factors that influence eating behavior. This therapy does not deal with weight, food, or body image at all.
The goals are the following:
- To express feelings.
- To discover how to tolerate uncertainty and change.
- To develop a strong sense of individuality and independence.
- To address any relevant sexual issues or traumatic or abusive event in the past that might be a contributor of the eating disorder.
Family Therapy: Because of the major role family attitudes play in eating disorders, one of the first steps in treating the patient with early-onset anorexia is to also treat the family. Family therapy can be useful for both younger and older patients.
If the patient is hospitalized, experts recommend that family therapy start after the patient has gained weight, but before discharge. It should usually continue after the patient has left the hospital.
The feelings of intense guilt and anxiety that caregivers experience are probably similar to those produced by living with a person who is suicidal. An over-involved parent may even support the patient's eating disorder for various reasons:
- Some parents may be afraid of releasing some underlying anger or grief directed at the patient.
- Other parents may identify with the goal of thinness and not even perceive that their child is unhealthily underweight.
In such cases, it is extremely important that the family members fully understand the danger of this disorder and that they are collaborating in their child's illness, or even death, by encouraging this state.
Medicine and medications:
Medicines such as antidepressants may reduce the frequency of the binge-purge episodes of bulimia. They may also be used to treat other mental health problems, such as depression, that often occur along with bulimia. And you may need antacids to decrease stomach acid or bulk laxatives such as Citrucel to replace the overuse of more harsh laxatives.
Medication Choices: Antidepressant medicines are used to reduce the frequency of binge-purge cycles and treat any related depression or anxiety.
The most common antidepressants prescribed for bulimia are selective serotonin reuptake inhibitors (SSRIs) such as:
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
- Fluoxetine (Prozac).
- Sertraline (Zoloft).
- Paroxetine (Paxil).
- Fluvoxamine (Luvox).