Bulimia

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Overview
Bulimia nervosa, commonly known as bulimia, is an eating disorder. It is a psychological condition in which the subject engages in recurrent binge eating followed by intentional purging. This purging is done in order to compensate for the excessive intake of food, usually to prevent weight gain. Purging can take the form of vomiting; inappropriate use of laxatives, enemas, diuretics or other medication; or excessive physical exercise. The word bulimia comes from the Latin (būlīmia) from the Greek βουλῑμια (boulīmia), ravenous hunger, compounded from βους (bous), ox + λῑμος (līmos), hunger.

DSM-IV-TR criteria
The following five criteria should be met for a patient to be diagnosed with bulimia nervosa:
 * 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 in order 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.

History of bulimia nervosa
Bulimia nervosa was first described by Gerald Russell in 1977 while he worked at the Royal Free Hospital, London. Bulimia nervosa has been recognized as an autonomous eating disorder by the American Psychiatric Association since 1980. The word “bulimia” is Latin, getting its roots from the Greek word “boulimia” which directly translates to mean “extreme hunger”.

Causes
Bulimia is often less about food, and more to do with deep psychological issues and profound feelings of lack of control. Binge/purge episodes can be severe, sometimes involving rapid and out of control feeding that can stop when the sufferers "are interrupted by another person" or when their stomach hurts from over-extension. This cycle may be repeated several times a week or, in serious cases, several times a day. Sufferers can often "use the destructive eating pattern to gain control over their lives".

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

Environmental factors
The disorder is more prevalent in Caucasian groups, but is becoming a rising problem in the African American and Hispanic communities. There are higher rates of eating disorders in groups involved in activities that put an emphasis on thinness and body type (such as gymnastics, dance and cheerleading, figure skating, and other sports and activities in which a slender body is believed to be most appealing).

Definition
An eating disorder, common especially among young women of normal or nearly normal weight, that is characterized by episodic binge eating and followed by feelings of guilt, depression, and self-condemnation. It is often associated with measures taken to prevent weight gain, such as self-induced vomiting, the use of laxatives, dieting, or fasting.

Patterns of bulimic cycles
The frequency of bulimic cycles will vary from person to person; some might binge and purge several times a day. Some bulimics may be able to vomit without gagging themselves after eating. "Bulimics may go through a severe binge/purge cycle that is very devastating to the body. They may hide or hoard food and overeat when stressed or worried or upset. The bulimic may feel a loss of control during a binge and consume very large quantities of food (over 20,000 calories.") Others will eat socially but may be bulimic in private. Some people do not regard their illness as a problem, while others despise and fear the vicious and uncontrollable cycle they are in. Bulimics may appear to be underweight, normal weight or even overweight. Every bulimic is completely different in "how much" they purge. Some binge, some don't. Oftentimes when the urge "hits", they will go to great lengths to purge, as if an uncontrollable urge or force is making them do so. Medical evidence shows that the chemicals released when purging might make a person feel "high". This can also lead to extreme dehydration and electrolyte imbalances.

Subtypes of bulimia
The specific subtypes of bulimia are distinguished by the way the bulimic relieves themselves of the binge.


 * Purging type: The purging type involves self-induced vomiting, laxatives, diuretics, tapeworms, enemas, or ipecac, as a means of rapidly extricating the contents from their body. This subtype is generally more prevalent, and can involve one or more of the above methods.


 * Non-Purging Type: This type of bulimia is rarely found (occurring in only approximately 6%-8% of cases), as it is a less effective means of ridding the body of such a large number of calories. This type of bulimia involves engaging in excessive exercise or fasting following a binge in order to counteract the large amount of calories previously ingested. This is frequently observed in purging-type bulimics as well, however this method is, by definition, not their primary form of weight control following a binge.

Consequences of bulimia nervosa
Bulimia can result in following health problems:
 * Malnutrition
 * Dehydration
 * Electrolyte imbalance (Can lead to cardiac arrest, which can also result in brain damage by stroke.)
 * Hyponatremia
 * Damaging of the voice
 * Vitamin and mineral deficiencies
 * Teeth erosion and cavities, gum disease
 * Sialadenosis (salivary gland swelling)
 * 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 apparent in the lower eyelids due to the high pressure of blood in the face during vomiting.
 * Callused or bruised fingers
 * Dry or brittle skin, hair, and nails, or hair loss
 * Lanugo
 * Edema
 * Muscle atrophy
 * Decreased/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
 * Elevated blood sugar or 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
 * Potential 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.

Diagnosis
As mentioned earlier, all six of the criteria listed in the DSM are required for a classic diagnosis of bulimia nervosa. However, these symptoms are often difficult to spot, especially since, unlike anorexia nervosa, in order to be classified as bulimic the person must be of normal or higher weight. Likewise, the person is less likely to drop a significant amount of weight on a continual basis as does the anorexic, making the physical symptoms less noticeable, despite the fact that internal bodily functions are suffering. Because this disorder carries a great deal of shame, the bulimic will desperately try to hide their symptoms from family and friends. This disorder 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 nervosa has proven to be fatal, as malnutrition takes a serious toll on every organ in your body. If any of the symptoms above are noticed one should consult with a doctor or psychologist for further assistance.

Related psychological disorders
It is not uncommon that a patient with bulimia nervosa will also have some anxiety or mood disorder as well. Most commonly associated with bulimia is the incidence of anxiety, one study noted this in 75% of bulimic patients. Also prominent in bulimic patients are mood disorders, most commonly depression as well as substance abuse issues. However recent researchers suggest that depression is a consequence of the eating disorder itself, rather than the other way around. They 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, bulimic females also express a need to solicit sympathy, affection, and emotional support.

The stereotypical bulimic is well educated, good-looking, high achieving and a perfectionist. Bulimics are generally raised in dysfunctional families. Many patients also display alexithymia, the inability to consciously experience and express emotions.

Differences between anorexia nervosa and bulimia nervosa
The main criteria differences involve weight, as an anorexic must technically be classified as underweight (defined as a BMI < 18.5, though to be diagnosed with anorexia, the patient generally must have a BMI 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, though they may occur. In the rare instance that this is observed, that is, the patient binges and purges as well as 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, those with bulimia nervosa 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 to needing help, or that a problem even exists in the first place. Similarly, both anorexics and bulimics have an overpowering sense of self that is determined by their weight and their perceptions of it. They both place all their achievements and successes as the result of their body, and for this reason are often depressed as they feel they are consistently failing to achieve the perfect body. For the bulimic, because s/he cannot achieve the low weight s/he feels physically that s/he is a failure and this outlook infiltrates into all aspects of her/his life. The anorexic cannot see that s/he is truly underweight and is constantly working towards a goal that s/he will never meet. Because of this misconception s/he will never be thin enough, and therefore will be always working towards this unattainable goal. S/he too allows this failure at achieving the “perfect body” to define his/her 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 of bulimia nervosa
Treatment is most effective when it is implemented early on in the development of the disorder. Unfortunately, since this disorder is often easier to hide and less physically noticeable, diagnosis and treatment often come when the disorder has already become a static part of the patient’s life. Historically, those with bulimia were often hospitalized to end the pattern and then released as soon as the symptoms had been relieved. However, this is now infrequently used, as this only addresses the surface of the problem, and soon after discharge the symptoms would often reappear as severe, if not worse, than when they had originally been.

There are several residential treatment centers which offer long term support, counseling, and symptom interruption. The most popular form of treatment for the disorder involves some form of therapy, often group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatments and are members of these same treatment groups. This is because anorexia and bulimia often go hand in hand, and it is not unlikely that one has at some point participated in 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, as well as the actual food symptoms. In combination with therapy, many psychiatrists will prescribe anti-depressants or anti-psychotics. Anti-depressants come in different forms, and the most promising drug to respond to bulimia has been Prozac. In a study done with 382 bulimia patients those who took between 20-60 mg of the drug reduced their symptoms from 45% to 67%, respectively. However it is quite possible that several other drugs could be more effective. Often insurance companies will not pay for other drugs for the patient until he or she has tried Prozac, because it has some positive outcome results.

Anti-psychotics are also used, but in smaller doses than are used 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, has discovered that some female patients suffer from a hormonal imbalance of testosterone and respond to a course of contraceptive pill containing oestrogen, resulting in a reduction of the symptoms of bulimia nervosa. This research is in its early stages and further studies will be required to determine the efficacy and application of such a treatment.

Mortality risk
Eating disorders have one of the highest death rates of all mental illnesses. The Eating Disorders Association (UK) estimates a 10% mortality rate. An 18% mortality rate has been suggested for Anorexia Nervosa. In addition to the risk of suicide, “death can occur after severe binging in bulimia nervosa as well”. For perspective, these death rates are higher than those of some forms of cancer.

However, the mortality rate related to bulimia is quite low, when compared to anorexia nervosa.

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

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
 * those positioned in the higher echelons of 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. Additionally, in the case of older persons with the disease, symptoms may have continued untreated for several years or decades, which results in the behaviors becoming increasingly ingrained and more difficult to confront.

There can be a popular assumption that eating disorders are ‘female diseases’, but the illnesses do not discriminate based on gender, and many males also suffer from them (about 2-8% of all sufferers). Unfortunately, many don't get the help they need for fear being thought of as homosexual or having a "Women's disease"

Prevention
Currently, there is no known way to prevent the onset of bulimia nervosa. Less social and cultural emphasis on physical perfection might help, but it is difficult to make sweeping societal changes. And, as stressed earlier, the best method for preventing the progression of this disorder is early intervention by contacting your medical health professional and receiving psychotherapy. Adults have an immeasurable impact on their children, and focusing on developing a healthy lifestyle is key to raising healthy children in all aspects of life. Teaching children to adopt a healthy diet as a way of life and incorporating fun activities into their day will allow this to become second nature to them. Children should also 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 method of teaching, and curtailing your own self-criticism and behavior will reflect substantially on your children’s impressions of themselves.

Early results from the Karolinska Institutet suggests that one possible treatment is to take a course of birth control pills containing oestrogen to offset a possible over production of the male hormone testosterone. This appears to alleviate some of the symptoms however further research is needed.

Acknowledgements
The content on this page was first contributed by: C. Michael Gibson, M.S., M.D.

List of contributors: