What is bulimia nervosa?
Bulimia nervosa is a serious eating disorder marked by a destructive pattern of binge-eating and recurrent inappropriate behavior to control one's weight. It can occur together with other psychiatric disorders such as depression, obsessive-compulsive disorder, substance dependence, or self-injurious behavior. Binge eating is defined as the consumption of excessively large amounts of food within a short period of time. The food is often sweet, high in calories, and has a texture that makes it easy to eat fast. "Inappropriate compensatory behavior" to control one's weight may include purging behaviors (such as self-induced vomiting, abuse of laxatives, diuretics, or enemas) or non-purging behaviors (such as fasting or excessive exercise). For those who binge eat, sometimes any amount of food, even a salad or half an apple, is perceived as a binge and is vomited.
People with bulimia nervosa often feel a lack of control during their eating binges. Their food is usually eaten secretly and gobbled down rapidly with little chewing. A binge is usually ended by abdominal discomfort. When the binge is over, the person with bulimia feels guilty and purges to rid his or her body of the excess calories. To be diagnosed with bulimia, a person must have had, on average, a minimum of two binge-eating episodes a week for at least three months. The first problem with any eating disorder is constant concern with food and weight to the exclusion of almost all other personal concerns.
Who develops bulimia?
Bulimia nervosa typically begins in adolescence or early adulthood. Like anorexia nervosa, bulimia mainly affects females. Only ten percent to 15 percent of affected individuals are male. An estimated two percent to three percent of young women develop bulimia, compared with the one-half to one percent that is estimated to suffer from anorexia. Studies indicate that about 50 percent of those who begin an eating disorder with anorexia nervosa later become bulimic.
It is believed that more than five million individuals experience an eating disorder (bulimia nervosa or anorexia nervosa) in this country alone. It is ten times more common in women than men, with greatest prevalence occurring in adolescents and college-age young adults. This indicates a need for concern and preventive measures on college campuses across the country, especially for female students.
How do people with bulimia control their weight?
People with bulimia are overly concerned with body shape and weight. They make repeated attempts to control their weight by fasting and dieting, vomiting, using drugs to stimulate bowel movements and urination, and exercising excessively. Weight fluctuations are common because of alternating binges and fasts. Unlike people with anorexia, people with bulimia are usually within a normal weight range. However, many heavy people who lose weight begin vomiting to maintain the weight loss.
What are the common signs of bulimia?
Constant concern about food and weight is a primary sign of bulimia. Common indicators that suggest the self-induced vomiting that persons with bulimia experience are the erosion of dental enamel (due to the acid in the vomit) and scarring on the backs of the hands (due to repeatedly pushing fingers down the throat to induce vomiting).
A small percentage of people with bulimia show swelling of the glands near the cheeks called parotid glands. People with bulimia may also experience irregular menstrual periods and a decrease in sexual interest. A depressed mood is also commonly observed as are frequent complaints of sore throats and abdominal pain. Despite these telltale signs, bulimia nervosa is difficult to catch early. Binge eating and purging are often done in secret and can be easily concealed by a normal-weight person who is ashamed of his or her behavior, but compelled to continue it because he or she believes it controls weight. Characteristically, these individuals have many rules about food -- e.g. good foods, bad foods -- and can be entrenched in these rules and particular thinking patterns. This preoccupation and these behaviors allow the person to shift their focus from painful feelings and reduce tension and anxiety perpetuating the need for these behaviors.
Are there any serious medical complications?
Persons with bulimia -- even those of normal weight -- can severely damage their bodies by frequent binging and purging. Electrolyte imbalance and dehydration can occur and may cause cardiac complications and, occasionally, sudden death. In rare instances, binge eating can cause the stomach to rupture, and purging can result in heart failure due to the loss of vital minerals like potassium.
Do we know what causes bulimia?
The current obsession with thinness in our culture certainly has a large influence. There is some evidence that obesity in adolescence or familial tendency toward obesity predisposes an individual to the development of the disorder. Parents’ anxiety over a chubby child can perhaps also be a contributor. Some individuals with bulimia report feeling a "kind of high" when they vomit. People with bulimia are often compulsive and may also abuse alcohol and drugs. Eating disorders like anorexia and bulimia tend to run in families, and girls are most susceptible. Recently, scientists have found certain neurotransmitters (serotonin and norepinephrine) to be decreased in some persons with bulimia. Most likely, it is a combination of environmental and biological factors that contribute to the development and expression of this disorder. During the early 1970s, before the prevalence of bulimia was more widely recognized, almost all persons with an eating disorder believed they had invented the behaviors and that no one else had such a problem. As in anorexia nervosa, the behaviors associated with bulimia provide temporary relief from tension and allow ill persons to focus less on problems perceived as unresolvable and to instead focus on body weight and food.
Is treatment available for persons with bulimia?
Most people with bulimia can be treated through individual outpatient therapy because they aren't in danger of starving themselves as are persons with anorexia. However, if the bulimia is out of control, admission to an eating disorders treatment program may help the individual let go of their behaviors so they can concentrate on treatment.
Group therapy is especially effective for college-aged and young adult women because of the understanding of the group members. In group therapy they can talk with peers who have similar experiences. Additionally, support groups can be helpful as they can be attended for as long as necessary, have flexible schedules, and generally have no charge. Support groups, however, do not take the place of treatment. Sometimes a person with an eating disorder is unable to benefit from group therapy or support groups without the encouragement of a personal therapist.
Cognitive-behavioral therapy, either in a group setting or individual therapy session, has been shown to benefit many persons with bulimia. It focuses on self-monitoring of eating and purging behaviors as well as changing the distorted thinking patterns associated with the disorder. Cognitive-behavioral therapy is often combined with nutritional counseling and/or antidepressant medications such as fluoxetine (Prozac).
Treatment plans should be adjusted to meet the needs of the individual concerned, but usually a comprehensive treatment plan involving a variety of experts and approaches is best. It is important to take an approach that involves developing support for the person with an eating disorder from the family environment or within the patient’s community environment (support groups or other socially supportive environments).
What about prevention?
Prevention research is increasing as scientists study the known "risk factors" to these disorders. Given that bulimia and other eating disorders are multi-determined and affect young women, there is preliminary information on the role and extent such factors as self esteem, resilience, family interactions, peer pressure, the media and dieting might play in its development. Advocacy groups are also engaged in prevention through efforts such as removing damaging articles from teen magazines on "dieting" and the importance of "being thin."
Reviewed by Barbara Wolfe, RN, PhD, FAAN June 2003