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.
The handbook for mental health professionals to aid in diagnosis is the Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM-IV-TR. This book categorizes bulimia nervosa as an eating disorder, along with anorexia nervosa .
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 overexercising 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 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.
A small proportion of bulimics exercise excessively or fast after a binge instead of purging.
Patients with bulimia 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.
Causes and symptoms
As of 2002, bulimia nervosa is understood to be a complex disorder with multiple factors contributing to its development. Researchers presently disagree about the degree of influence exerted by genetic factors, psychological patterns in the family of origin, and social trends.
GENETIC. Two recently published reviews (in 1999 and 2000) suggest that there is some heritability for bulimia. 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 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. Some of these theories maintain that:
- 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.
Nutrition experts have pointed to the easy availability of foods high in processed carbohydrates in developed countries as a social factor that contributes to the incidence of bulimia. One study found that subjects who were given two slices of standard mass-produced white bread with some jelly had their levels of serotonin increased temporarily by 450%. This finding suggests that bulimics who binge on ice cream, bread, cookies, pizza, and fast food items that are high in processed carbohydrates are simply manipulating their neurochemistry in a highly efficient manner. The incidence of bulimia may be lower in developing countries because diets that are high in vegetables and whole-grain products but low in processed carbohydrates do not affect serotonin levels in the brain as rapidly or as effectively.
The DSM-IV-TR specifies that bingeing and the inappropriate attempts to compensate for it must occur twice a week for three months on average to meet the diagnostic criteria for bulimia nervosa.
A second criterion of bulimia nervosa is exaggerated concern with body shape and weight. Bulimia can be distinguished from body dysmorphic disorder (BDD) by the fact that people with BDD usually focus on a specific physical feature— most commonly a facial feature— rather than overall shape and weight. Bulimics do, however, resemble patients with BDD in that they have distorted body images.
Bulimia is associated with a number of physical symptoms. Binge eating by itself rarely causes serious medical complications, but it is associated with nausea, abdominal distension and cramping, slowed digestion, and weight gain.
Self-induced vomiting, on the other hand, may have serious medical consequences, including:
- Erosion of tooth enamel, particularly on the molars and maxillary incisors. Loss of tooth enamel is irreversible.
- Enlargement of the salivary glands.
- Scars and calloused areas on the knuckles from contact with the teeth.
- Irritation of the throat and esophagus from contact with stomach acid.
- Tearing of mucous membranes in the upper gastrointenstinal tract or perforation of the esophagus and stomach wall. Perforation of part of the digestive tract is a rare complication of bulimia but is potentially fatal.
- Electrolyte imbalances. The loss of fluids from repeated vomiting and laxative abuse can deplete the body's stores of hydrogen chloride, potassium, sodium, and magnesium. Hypokalemia (abnormally low levels of potassium in the blood) is a potential medical emergency that can lead to muscle cramps, seizures , and heart arrhythmias.
Other physical symptoms associated with bulimia include irregular menstrual periods or amenorrhea; petechiae (pinhead-sized bruises from capillaries ruptured by increased pressure due to vomiting) in the skin around the eyes and rectal prolapse (the lowering of the rectum from its usual position).
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 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.
The diagnosis of bulimia nervosa is made on the basis of a physical examination, a psychiatric assessment, the patient's eating history, and the findings of laboratory studies. Patients who do not meet the full criteria for bulimia nervosa may be given the diagnosis of subsyndromal bulimia or of eating disorder not otherwise specified (EDNOS).
Patients suspected of having bulimia nervosa should be given a complete physical examination because the disorder has so many potential medical complications. In addition, most bulimics are close to normal weight or only slightly overweight, and so do not look outwardly different from most people of their sex in their age group. The examination should include not only vital signs and an assessment of the patient's height and weight relative to age, but also checking for such signs of bulimia as general hair loss, abdominal soreness, swelling of the parotid glands, telltale scars on the back of the hand, petechiae, edema, and teeth that look ragged or "moth-eaten."
Psychiatric assessment of patients with bulimia usually includes four components:
- A thorough history of body weight, eating patterns, diets, typical daily food intake, methods of purging (if used), and concept of ideal weight.
- A history of the patient's significant relationships with parents, siblings, and peers, including present or past physical, emotional, or sexual abuse.
- A history of previous psychiatric treatment (if any) and assessment of comorbid (occurring at the same time as the bulimia) mood, anxiety, substance abuse, or personality disorders .
- Administration of standardized instruments that measure attitudes toward eating, body size, and weight. Common tests for eating disorders include the Eating Disorder Examination; the Eating Disorder Inventory; the Eating Attitude Test, or EAT; and the Kids Eating Disorder Survey.
Laboratory tests ordered for patients suspected of having bulimia usually include a complete blood cell count, blood serum chemistry, thyroid tests, and urinalysis. If necessary, the doctor may also order a chest x ray and an electrocardiogram (EKG). Typical findings in patients with bulimia include low levels of chloride and potassium in the blood, and higher than normal levels of amylase, a digestive enzyme found in saliva.
Treatment for bulimia nervosa typically involves several therapy approaches. It is, however, complicated by several factors.
First, patients diagnosed with bulimia nervosa frequently have coexisting psychiatric disorders that typically include major depression, dysthymic disorder , anxiety disorders, substance abuse disorders, or personality disorders. In the case of depression, the mood disorder may either precede or follow the onset of bulimia, and, with bulimia, the prevalence of depression is 40%–70%. With regard to substance abuse, about 30% of patients diagnosed with bulimia nervosa abuse either alcohol or stimulants over the course of the eating disorder. The personality disorders most often diagnosed in bulimics are the so-called Cluster B disorders— borderline, narcissistic, histrionic, and antisocial. Borderline personality disorder is a disorder characterized by stormy interpersonal relationships, unstable self-image, and impulsive behavior. People with narcissistic personality disorder believe that they are extremely important and are unable to have empathy for others. Individuals with histrionic personality disorder seek attention almost constantly and are very emotional. Antisocial personality disorder is characterized by a behavior pattern of a disregard for others' rights— people with this disorder often deceive and mainpulate others. A number of clinicians have noted that patients with bulimia tend to develop impulsive and unstable personality disturbances whereas patients with anorexia tend to be more obsessional and perfectionistic. Estimates of the prevalence of personality disorders among patients with bulimia range between 2% and 50%. The clinician must then decide whether to treat the eating disorder and the comorbid conditions concurrently or sequentially. It is generally agreed, however, that a substance abuse disorder, if present, must be treated before the bulimia can be effectively managed. It is also generally agreed that mood disorders and bulimia can be treated concurrently, often using antidepressant medication along with therapy.
Second, the limitations on treatment imposed by managed care complicate the treatment of bulimia nervosa. When the disorder first received attention in the 1970s, patients with bulimia were often hospitalized until the most significant physical symptoms of the disorder could be treated. As of 2002, however, few patients with bulimia are hospitalized, with the exception of medical emergencies related to electrolyte imbalances and gastrointestinal injuries associated with the eating disorder. Most treatment protocols for bulimia nervosa now reflect cost-containment measures.
The most common medications given to patients are antidepressants, because bulimia is so closely associated with depression. Short-term medication trials have reported that tricyclic antidepressants— desipramine , imipramine , and amitriptyline — reduce episodes of binge eating by 47%–91% and vomiting by 45%–78%. The monoamine oxidase inhibitors are not recommended as initial medications for patients diagnosed with bulimia because of their side effects. The most promising results have been obtained with the selective serotonin reuptake inhibitors, or SSRIs. Fluoxetine (Prozac) was approved in 1998 by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa. Effective dosages of fluoxetine are higher for the treatment of bulimia than they are for the treatment of depression. Although a combination of medication and cognitive-behavioral therapy is more effective in treating most patients with bulimia than medication alone, one team of researchers reported success in treating some bulimics who had not responded to psychotherapy with fluoxetine by itself.
A newer type of medication that shows promise in the treatment of bulimia nervosa is ondansetron, a drug that was originally developed to control nausea from chemotherapy and radiation therapy for cancer. Ondansetron acts to control the transmission of signals in nerves leading to the vagus nerve, which in turn governs feelings of fullness and the vomiting reflex. A British study reported that ondansetron normalized several aspects of eating behaviors in all the patients who received it during the study.
In addition to antidepressant or antinausea medications, such acid-reducing medications as cimetidine and ranitidine, or antacids, may be given to patients with bulimia to relieve discomfort in the digestive tract associated with irritation caused by stomach acid.
Cognitive-behavioral therapy (CBT) is regarded as the most successful psychotherapeutic approach to bulimia nervosa. CBT is intended to interrupt the faulty thinking processes associated with bulimia, such as preoccupations with food and weight, black-white thinking ("all or nothing" thinking, or thinking thoughts only at extreme ends of a spectrum) and low self-esteem, as well as such behaviors as the binge-purge cycle. Patients are first helped to regain control over their food intake by keeping food diaries and receiving feedback about their meal plans, symptom triggers, nutritional balance, etc. They are then taught to challenge rigid thought patterns as well as receiving assertiveness training and practice in identifying and expressing their feelings in words rather than through distorted eating patterns. About 50% of bulimic patients treated with CBT are able to stop bingeing and purging. Of the remaining half, some show partial improvement and a small minority do not respond at all.
Family therapy is sometimes recommended as an additional mode of treatment for patients with bulimia who come from severely troubled or food-obsessed families that increase their risk of relapsing.
Other mainstream therapies
Medical nutrition therapy, or MNT, is a recognized component of the treatment of eating disorders. Effective MNT for patients with bulimia involves an understanding of cognitive-behavioral therapy as well as the registered dietitian's usual role of assisting the physician with monitoring the patient's physical symptoms, laboratory values, and vital signs. In the treatment of bulimia, the dietitian's specialized knowledge of nutrition may be quite helpful in dealing with the myths about food and fad diets that many bulimic patients believe. The dietitian's most important task, however, is helping the patient to normalize her or his eating patterns in order to break the deprivation/bingeing cycle that is characteristic of bulimia nervosa. Calorie intake is usually based on retaining the patient's weight in order to prevent hunger, since hunger increases susceptibility to bingeing.
Recent studies in upstate New York have found that bright light therapy , of the type frequently prescribed for seasonal affective disorder (SAD), appears to be effective in reducing binge eating in patients diagnosed with bulimia. It also significantly relieved depressive symptoms, as measured by the patients' scores on the Beck Depression Inventory .
Alternative and complementary treatments
Alternative therapies that have been shown to be helpful for some patients in relieving the anxiety and muscular soreness associated with bulimia nervosa include acupuncture , massage therapy, hydrotherapy, and shiatsu.
Herbal remedies that have been used to calm digestive upsets in bulimic patients include teas made from chamomile or peppermint. Peppermint helps to soothe the intestines by slowing down the rate of smooth muscle contractions (peristalsis). Chamomile has been used to help expel gas from the digestive tract, a common complaint of bulimics. Both herbs have a wide margin of safety.
Some bulimic patients have responded well to yoga because its emphasis on focused breathing and meditation calls attention to and challenges the distorted thought patterns that characterize bulimia. In addition, the stretching and bending movements that are part of a yoga practice help to displace negative thoughts focused on the body's outward appearance with positive appreciation of its strength and agility. Lastly, since yoga is noncompetitive, it allows bulimics to explore the uniqueness of their bodies rather than constantly comparing themselves to other people.
The prognosis of bulimia depends on several factors, including age at onset, types of purging behaviors used (if any), and the presence of other psychiatric conditions or disorders. In many cases, the disorder becomes a chronic (long-term) condition; 20%–50% of patients have symptoms for at least five years in spite of treatment. The usual pattern is an alternation between periods of remission and new episodes of bingeing. Patients whose periods of remission last for a year or longer have a better prognosis; patients diagnosed with major depression or a personality disorder have a less favorable prognosis. Overall, however, the prognosis for full recovery from bulimia nervosa is considered relatively poor compared to other eating disorders.
Bulimia nervosa appears to produce changes in the functioning of the serotonin system in the brain. Serotonin is a neurotransmitter. A team of researchers at the University of Pittsburgh who compared brain images taken by positron emission tomography (PET) from bulimic women who had been in remission for a year or longer with brain images from healthy women found that the recovered bulimics did not have a normal age-related decline in serotonin binding. Since serotonin helps to regulate mood, appetite, and impulse control, the study may help to explain why some women may be more susceptible to developing bulimia than others.
As of 2002, the genetic factors in bulimia are not well understood. With regard to family influences, an important study published in December 2001 reported that the presence of eating problems in early childhood is a strong predictor of eating disorders in later life. The longitudinal study of 800 children and their mothers was based on psychiatric assessments of the subjects made in 1975, 1983, 1985, and 1992. The researchers found that a diagnosis of bulimia nervosa in early adolescence is associated with a nine-fold increase in risk for late adolescent bulimia and a 20-fold increase in risk for adult bulimia. Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. Given these findings, the most important preventive measure that can be taken in regard to bulimia nervosa is the establishment of healthful eating patterns and attitudes toward food in the family of origin.
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Academy for Eating Disorders. Montefiore Medical School, Adolescent Medicine, 111 East 210th Street, Bronx, NY 10467. (718) 920-6782.
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. <www.aacap.org> .
American Anorexia/Bulimia Association. 165 West 46th Street, Suite 1108, New York, NY 10036. (212) 575-6200.
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Center for the Study of Anorexia and Bulimia. 1 W. 91st St., New York, NY 10024. (212) 595-3449.
Rebecca J. Frey, Ph.D.