Bulimia nervosa

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Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Mark Warren, M.D., M.P.H.; Fellow, Academy of Eating Disorders [mailto:mwarren@eatingdisorderscleveland.org]

Overview
Bulimia nervosa, commonly known as bulimia, is an eating disorder and psychological condition in which the subject engages in recurrent binge eating followed by feelings of guilt, depression, and self-condemnation and intentional purging to compensate for the excessive eating, usually to prevent weight gain (see anorexia nervosa). Purging can take the form of vomiting, fasting, inappropriate use of laxatives, enemas, diuretics or other medication, or excessive physical exercise. The cycle damages bodily organs. Bulimia is common especially among young women of normal or nearly normal weight.

The word bulimia comes from the Latin (būlīmia) from the Greek βουλῑμια (boulīmia), ravenous hunger, compounded from βους (bous), ox + λῑμος (līmos), hunger.

History
Bulimia was first described in 1977 by Boskind-Lodahl and Gerald Russell, who worked at the Royal Free Hospital, London. It has been recognized as an autonomous eating disorder by the American Psychiatric Association since 1980.

Types
Two subtypes of bulimia are distinguished by the way the bulimic relieves themselves of the binge.

Purging Type is the more common type of bulimia, and involves any of self-induced vomiting, laxatives, diuretics, tapeworms, enemas, or ipecac, to rapidly extricate the contents from their body.

Non-Purging Type occurs in only approximately 6%-8% of bulimia cases, as it is a less effective means of ridding the body of such a large number of calories. It involves doing excessive exercise or fasting after a binge, to counteract the large amount of calories previously ingested. This often occurs in purging-type bulimics but is a secondary form of weight control.

Causes
Bulimia is related to deep psychological issues and feelings of lack of control. Sufferers often use the destructive eating pattern to feel in control over their lives. They may hide or hoard food and overeat when stressed or upset. They may feel a loss of control during a binge, and consume great quantities of food (over 20,000 calories.")

There are higher rates of eating disorders in groups involved in activities that emphasize thinness and body type, such as gymnastics, dance and cheerleading, figure skating. Bulimia is more prevalent among Caucasians, but is increasing among African Americans and Hispanics.

In one study, diagnosis of bulimia was correlated with high testosterone and low estrogen levels, and normalizing these levels with combined oral contraceptive pills reduced cravings for fat and sugar.

Diagnosis
The criteria for diagnosing a patient with bulimia are
 * 1) Recurrent episodes of binge eating.  An episode of binge eating is characterized by both of the following:
 * 2) Eating, in a fixed period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
 * 3) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
 * 4) Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
 * 5) The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
 * 6) Self-evaluation is unduly influenced by body shape and weight.
 * 7) The disturbance does not occur exclusively during episodes of anorexia nervosa.

See the Diagnostic and Statistical Manual of Mental Disorders. If any of these symptoms are noticed, a doctor or psychologist should be contacted. However, these symptoms are often difficult to spot. Unlike anorexia nervosa, the person must be of normal or higher weight and is less likely to drop a significant amount of weight on a continual basis. Because bulimia carries a great deal of shame, the bulimic desperately tries to hide the symptoms from family and friends. Bulimia is more likely to span over a lifetime unnoticed, causing a great deal of isolation and stress for the suffering individual. Despite the frequent lack of obvious physical symptoms, bulimia has proven to be fatal, as malnutrition takes a serious toll on every bodily organ.

Cyclic patterns
Bulimics go through cycles of over-eating and purging, that may be severe and devastating to the body. They sometimes involve rapid and out-of-control feeding that stops when the bulimic is interrupted by another person or when his/her stomach hurts from over-extension. This cycle may be repeated several times a week or, in serious cases, several times a day.

Some bulimics eat secretly, others eat socially but are bulimic in private. They also differ in "how much" they purge. Some can vomit without gagging themselves after eating. Often when the urge hits, they go to great lengths to purge, as if an uncontrollable urge is making them do so. Medical evidence shows that the chemicals released when purging may make a person feel "high". This can also lead to extreme dehydration and electrolyte imbalances.

Some bulimics do not regard their cycles as a problem, while others despise and fear the vicious and uncontrollable cycle. Bulimics may appear underweight, normal weight or overweight.

Consequences
Bulimia can cause following health problems:
 * Malnutrition
 * Dehydration
 * Electrolyte imbalance, which can cause cardiac arrest or brain damage by stroke
 * Hyponatremia
 * Damaging of the voice
 * Vitamin and mineral deficiencies
 * Teeth erosion and cavities, gum disease
 * Salivary gland swelling (sialadenosis)
 * Potential for gastric rupture during periods of binging
 * Esophageal reflux
 * Irritation, inflammation, and possible rupture of the esophagus
 * Laxative dependence
 * Peptic ulcers and pancreatitis
 * Emetic toxicity due to ipecac abuse
 * Swelling of the face and cheeks, especially the lower eyelids, due to the high pressure of blood in the face during vomiting; for the same reason Purpura can occur, a rash caused by burst blood vessels.
 * Callused or bruised fingers
 * Dry or brittle skin, hair, and nails, or hair loss
 * Lanugo
 * Edema
 * Muscle atrophy
 * Decreased or increased bowel activity
 * Digestive problems that may be triggered, including celiac, Crohn's Disease
 * Low blood pressure (hypotension)
 * Orthostatic hypotension
 * High blood pressure (hypertension)
 * Iron deficiency
 * Anemia
 * Hormonal imbalances
 * Hyperactivity
 * Depression
 * Insomnia
 * Amenorrhea
 * Infertility
 * High risk pregnancy, miscarriage, still-born babies
 * Diabetes
 * High blood sugar (hyperglycemia)
 * Ketoacidosis
 * Osteoporosis
 * Arthritis
 * Weakness and fatigue
 * Chronic Fatigue Syndrome
 * Cancer of the throat or voice box
 * Liver failure
 * Kidney infection and failure
 * Heart failure, heart arrhythmia, angina
 * Seizure
 * Paralysis
 * Death caused by heart attack or heart failure; lung collapse; internal bleeding, stroke, kidney failure, liver failure; pancreatitis, gastric rupture, perforated ulcer, depression and suicide.

Related psychological disorders
Many bulimics also have anxiety or mood disorders. One study found anxiety in 75% of bulimic patients. Prominent mood disorders include depression and substance abuse. Recent research suggests that depression is caused by the eating disorder. Bulimics are also more likely to attempt suicide and engage in impulsive behaviors.

Bulimic females typically have a less favorable opinion of themselves than control groups. They are more pessimistic, more ambivalent towards others, strive for less recognition in areas that are socially significant or require leadership. However, they also express a need to solicit sympathy, affection, and emotional support.

Bulimics are usually raised in dysfunctional families. Many also display alexithymia, the inability to consciously experience and express emotions.

Differences from anorexia nervosa
The main criteria differences involve weight: an anorexic must have a body mass index of less than 17.5. Typically an anorexic is defined by the refusal to maintain a normal weight by self-starvation.

Another criterion which must usually be met is amenorrhea, the loss of a female's menstrual cycle not caused by the normal cessation of menstruation during menopause for a period of three months. Generally the anorexic does not engage in regular binging and purging sessions. If binging and purging occurs but rarely, and the patient also fails to maintain a minimum weight, they are classified as a purging anorexic, due to the underweight criterion being met and cessation of menstruation.

Characteristically, bulimics feel more shame and out of control with their behaviors, as the anorexic meticulously controls their intake, a symptom that calms their anxiety around food as s/he feels s/he has control of it, naïve to the notion that it, in fact, controls him/her. For this reason, the bulimic is more likely to admit to having a problem, as they do not feel they are in control of their behavior. The anorexic is more likely to believe they are in control of their eating and much less likely to admit that a problem exists.

Anorexics and bulimics have an overpowering sense of self determined by their body and their perceptions of it. They trace all their achievements and successes to it, and so are often depressed as they feel they are consistently failing to achieve the perfect body. Bulimics feel that they are a failure because s/he cannot achieve a low weight, and this outlook infiltrates into all aspects of their lives. Anorexics cannot see that they are underweight and constantly work towards a goal that they cannot meet. They too allow this failure to define their self worth. As both the anorexic and bulimic never feel satisfaction in the more important part of their lives, depression often accompanies these disorders.

Treatment
Treatment is most effective early in the development of the disorder, but since bulimia is often easy to hide, diagnosis and treatment often come when the disorder has already become a static part of the patient’s life

Historically, bulimics were often hospitalized to end the pattern and then released as soon as the symptoms had been relieved. But this is now infrequently used, as this only addresses the surface of the problem, and soon after discharge the symptoms often reappeared as severe, if not worse.

Several residential treatment centers offer long term support, counseling, and symptom interruption. The most popular form of treatment involves therapy, often group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatment and are members of these same treatment groups. This is because anorexia and bulimia often go hand in hand, and often patients have at some point suffered from both. Some refer to this as "symptom swapping". These forms of therapy address both the underlying issues which cause the patient to engage in these behaviors, and the food symptoms. In combination with therapy, many psychiatrists prescribe anti-depressants or anti-psychotics. Anti-depressants come in different forms, and the most promising one has been Prozac. In a study of 382 bulimics, those who took 20 to 60 mg of Prozac reduced their symptoms from 45% to 67%, respectively. It is possible that several other drugs could be more effective, but often insurance companies will not pay for other drugs until the patient has tried Prozac, because it has some positive outcome results.

Anti-psychotics are used in smaller doses than for treating schizophrenia. With an eating disorder, the patient perceives reality differently and has difficulty grasping what it is like to eat normally. Unfortunately, since this disorder has only recently been recognized by the DSM, long-term outcomes of people with the disorder are unknown. Current research indicates that up to 30% of patients rapidly relapse, while 40% are chronically symptomatic.

The rate in which the patient receives treatment is the most important factor affecting prognosis. Those who receive treatment early on for the disorder have the highest and most permanent recovery rates.

Dr Sabine Naessén from the Karolinska Institute discovered that some female patients suffer from a hormonal imbalance of over-production of the male hormone testosterone, that can be countered by a contraceptive pill containing estrogen, resulting in a reduction of the symptoms of bulimia. Further studies are required to determine the efficacy of such a treatment.

Mortality
Eating disorders have one of the highest death rates of all mental illnesses. The Eating Disorders Association of UK estimates it at 10%. An 18% mortality rate has been suggested for anorexia. These death rates are higher than those of some forms of cancer.

The rate for bulimia is much lower than for anorexia. Death can occur after severe binging, or from suicide.

At-risk groups
Risk factors for bulimia are similar to those of other eating disorders, such as anorexia.

The groups listed below are considered to be at the highest risk:
 * those of age 10 through to 25 (though typically bulimia tends to start in late teens or early 20s)
 * athletes
 * those with/with a history of anorexia
 * students who are under heavy workloads
 * those who have suffered traumatic events in their lifetime such as child abuse and sexual abuse
 * people raised in dysfunctional families
 * those positioned higher on the socioeconomic scale
 * the highly intelligent and/or high-achievers
 * perfectionists

However, the disorder can occur in people of all ages and both sexes. There is a new rise of cases in men. In older patients, symptoms may have continued untreated for several years or decades, making the behaviors increasingly ingrained and difficult to confront. A popular assumption is that eating disorders are female diseases, but 2-8% of patients are male. Unfortunately, many men do not get the help they need for fear being thought of as homosexual or having a "Women's disease"

Prevention
There is no known way to prevent the onset of bulimia. Less social and cultural emphasis on physical perfection may help, but it is difficult to make sweeping societal changes. The best way to stop the progression of bulimia is early intervention by contacting a medical health professional and receiving psychotherapy. Adults have an immeasurable impact on their children. Teaching children to adopt a healthy diet as a way of life and incorporating fun activities into their day allows this to become second nature to them. Children should be taught an emphasis on their internal characteristics and qualities rather than the external focus so much of society and the media tend to focus on. Action is the best way of teaching, and the adults' self-criticism and behavior reflects substantially on their children’s impressions of themselves.