Bulimia nervosa is an eating disorder that involves repeated binge eating followed by purging the body of calories to avoid gaining weight. The person who has bulimia has an irrational fear of gaining weight and a distorted body image. Bulimia nervosa can have potentially fatal health consequences.
Bulimia is an eating disorder in which a person eats an unreasonably large amount of food in a short time (binges) and then rids the body of calories (purges). Purging is most often done by self-induced vomiting, but it can also be done by laxative, enema, or diuretic abuse. Alternately, some people with bulimia do not purge but use extreme exercising and post-binge fasting to burn calories. This can lead to serious injury. Non-purging bulimia is sometimes called exercise bulimia. Bulimia nervosa is officially recognized as a psychiatric disorder in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR), published by the American Psychiatric Association.
Bulimia nervosa is diagnosed when most of the following conditions are present:
Effects of bulimia on the body
Low potassium, magnesium, and sodium
Fear of gaining weight
Heart muscle weakened
Irregular heart beat
Low pulse and blood pressure
Abdominal cramping Bloating Constipation Diarrhea
Irregular bowel movements
Irregular or absent period
Teeth sensitive to hot and cold food
Tooth enamel erosion
Abrasion of knuckles Dry skin
Throat and esophagus
Blood in vomit
Soreness and irritation
Tears and ruptures
SOURCE: National Women's Health Information Center, Office on Women's Health, U.S. Department of Health and Human Services.
Many people with bulimia will consume 3,000–10,000 calories in an hour. For example, they will start out intending to eat one slice of cake and end up eating the entire cake. One distinguishing aspect of bulimia is how out of control people with bulimia feel when they are eating. They will eat and eat, continuing even when they feel full and become uncomfortable.
Most people with bulimia recognize that their behavior is not normal; they simply cannot control it. They usually feel ashamed and guilty over their binge/purge habits. As a result, they frequently become secretive about their eating and purging. They may, for example, eat at night after the family has gone to bed or buy food at the grocery store and eat it in the car before going home. Many people with bulimia choose high-fat, high-sugar foods that are easy to eat and easy to regurgitate. They become adept at inducing vomiting, usually by sticking a finger down their throat and triggering the gag reflex. After a while, they can vomit at will. Repeated purging has serious physical and emotional consequences.
Many individuals with bulimia are of normal weight, and a fair number of men who become bulimic were overweight as children. This makes it difficult for family and friends to recognize when someone is suffering from this disorder. People with bulimia may lie about induced vomiting and laxative abuse, although they may complain of symptoms related to their binge/purge cycles and seek medical help for those problems. People with bulimia tend to be more impulsive than people with other eating disorders. Lack of impulse control often leads to risky sexual behavior, anger management problems, and alcohol and drug abuse.
A subset of people with bulimia also have anorexia nervosa. Anorexia nervosa is an eating disorder that involves self-imposed starvation. These people often purge after eating only a small or a normalsized portion of food. Some studies have shown that up to 60% of people with bulimia have a history of anorexia nervosa.
Dieting is usually the trigger that starts individuals down the road to bulimia. Those who may develop bulimia May be very concerned about weight gain and appearance and may constantly be on a diet. They may begin by going on a rigorous low-calorie diet. Unable to stick with the diet, they then eat voraciously, far more than they need to satisfy their hunger, feel guilty about eating, and then exercise or purge to get rid of the unwanted calories. At first this may happen only occasionally, but gradually these sessions of bingeing and purging become routine and start to intrude on a person's friendships, daily activities, and health. Eventually these practices have serious physical and emotional consequences that need to be addressed by healthcare professionals.
Bulimia nervosa is primarily a disorder of industrialized countries where food is abundant and the culture values a thin appearance. Internationally, the rate of bulimia has been increasing since the 1950s. Bulimia is the most common eating disorder in the United States. Overall, about 3% of Americans have bulimia. Of these, 85%–90% are female. The rate is highest among adolescents and college women, averaging 5%–6%. In men, the disorder is more often diagnosed in homosexuals than in heterosexuals. Some experts believe that the number of people diagnosed with bulimia represents only the most severe cases and that many more people have bulimic tendencies, but are successful in hiding their symptoms. In one study, 40% of college women reported isolated incidents of bingeing and purging.
Bulimia affects people from all racial, ethnic, and socioeconomic groups. The disorder usually begins later in life than anorexia nervosa. Most people begin bingeing and purging in their late teens through their twenties. Men tend to start at an older age than women. About 5% of people with bulimia begin the behavior after age 25. Bulimia is uncommon in children under age 14.
Competitive athletes have an increased risk of developing bulimia nervosa, especially in sports where weight is tied to performance and where a low percentage of body fat is highly desirable. Jockeys, wrestlers, bodybuilders, figure skaters, cross-country runners, and gymnasts have higher than average rates of bulimia. People such as actors, models, cheerleaders, and dancers who are judged mainly on their appearance are also at high risk of developing the disorder. This same group of people is also at higher risk for developing anorexia nervosa. Some people are primarily anorexic and severely restrict their calorie intake while also purging the small amounts they do eat. Others move back and forth between anorexic and bulimic behaviors.
A report from the National Institute of Mental Health (NIMH) noted that approximately 16% of individuals with bulimia nervosa received treatment for a 12 month period of time, and 43% of individuals with this disorder were receiving lifetime treatment.
Bulimia nervosa is a complex disorder that does not have a single cause. Research suggests that some people have a predisposition toward bulimia and that something triggers the behavior, which then becomes self-reinforcing. Hereditary, biological, psychological, and social factors all appear to play a role.
Binge/purge cycles have physical consequences, including:
Diagnosis is based on several factors, including a patient history, physical examination, the results of laboratory tests, and a mental status evaluation. A patient history is less helpful in diagnosing bulimia than in diagnosing many diseases because many people with bulimia lie about their bingeing and purging and their use of laxatives, enemas, and medications. The patient may, however, complain about related symptoms such as fatigue or feeling bloated. Many people with bulimia are likely to express extreme concern about their weight during the examination.
A physical examination begins with weight and blood pressure and moves through the body looking for the signs listed above. Based on the physical exam and patient history, the physician may order laboratory tests. In general, these tests will include a complete blood count (CBC), urinalysis, and blood chemistries (to determine electrolyte levels). People suspected of extreme exercising may need to have x-rays to look for damage to bones, such as stress fractures.
Several different evaluations can be used to examine a person's mental state. A doctor or mental health professional will assess the individual's thoughts and feelings about themselves, their body, their relationships with others, and their risk for self-harm.
Treatment choices depend on the degree to which the bulimic behavior has resulted in physical damage and whether the person is a danger to him or herself. Hospital inpatient care may be needed to correct severe electrolyte imbalances that result from repeated vomiting and laxative abuse. Electrolyte imbalances can result in heart irregularities and other potentially fatal complications. Most people with bulimia do not require hospitalization. The rate of hospitalization is much lower than that for people with anorexia nervosa because many people with bulimia maintain a normal weight.
Day treatment or partial hospitalization, where the patient goes every day to an extensive treatment program, provides structured mealtimes, nutrition education, intensive therapy, medical monitoring, and supervision. If day treatment fails, the patient may need to be hospitalized or enter a full-time residential treatment facility.
Outpatient treatment provides medical supervision, nutrition counseling, self-help strategies, and psychotherapy. Self-help groups receive mixed reviews from healthcare professionals who work with people with bulimia. Some groups offer constructive support in stopping the binge/purge cycle, while others tend to reinforce the behavior.
Drug therapy helps many people with bulimia. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) have been approved by the United States Food and Drug Administration (FDA) for treatment of bulimia. These medications increase serotonin levels in the brain and are thought to affect the body's sense of fullness. They are used whether or not the patient shows signs of depression. Drug treatment should always be supplemented with psychotherapy.
A dietitian is part of the team needed to successfully treat bulimia. These professionals usually perform a dietary review along with nutritional counseling so that the recovering bulimic can plan healthy meals and develop a healthy relationship with food.
Medical intervention helps alleviate the immediate physical problems associated with bulimia. Medication can help the person with bulimia break the binge/purge cycle. However, drug therapy alone rarely produces recovery. Psychotherapy plays a major role in helping the individual with bulimia recover from the disorder. Several different types of psychotherapy are used depending on individual's situation. Generally, the goal of psychotherapy is to help individuals change their behaviors and develop a healthy attitude toward their body and food.
Some types of psychotherapy have been successful in treating people with bulimia:
The long-term outlook for recovery from bulimia is mixed. About half of all people with bulimia show improvement in controlling their behavior after short-term interpersonal or cognitive behavioral therapy with nutritional counseling and drug therapy. However, after three years, only about one-third are still doing well. Relapses are common, and binge/purge episodes and bulimic behavior often comes and goes for many years. Stress seems to be a major trigger for relapse.
The sooner treatment is sought, the better the chances of recovery. Without professional intervention, recovery is unlikely. Untreated bulimia can lead to death from causes such as rupture of the stomach or esophagus. Associated problems such as substance abuse, depression, anxiety disorders, and poor impulse control also contribute to the death rate.
To help prevent bulimia nervosa from developing, parents and guardians:
If parents suspect that their child has an eating disorder, they should not wait to intervene and get professional help. The sooner the disorder is recognized, the easier it is to treat.
Relapses happen to many people with bulimia. People who are recovering from bulimia can help prevent themselves from relapsing by doing the following:
See also Adolescent nutrition ; Anorexia nervosa ; Binge eating ; Body image ; Body mass index ; Childhood obesity ; Eating disorders ; Nutrition and mental health ; Oral health and nutrition ; Weight cycling .
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Tish Davidson, AM
Revised by Laura Jean Cataldo, RN, EdD