Bulimia Nervosa / AN EATING DISORDER
Contents
Physical effects of Bulimia Nervosa
Psychological effects
Bulimia Nervosa: Criteria For
Diagnosis
What Causes Bulimia Nervosa
How Do You Treat Bulimia
Nervosa
MultiDisciplinary Treatment
Team
Goals of treatment
Long Term Outcomes
Warning Signs of Bulimia NervosaIntroduction
Bulimia Nervosa (BN) is an
eating disorder, which typically affects 2% of adolescent/young adult women in
the United States and other western industrialized nations .[1] The word
“bulimia” means a condition characterized by perpetual insatiable hunger with
bouts of overeating. BN is a mental health disorder characterized by episodes
of overeating followed by some compensatory mechanism aimed at weight loss such
as underreating, use of laxatives, self-induced vomiting, or compulsive
over-exercise. Most people who have this disorder are characterized as
bulimics. The disorder is often associated with depression and anxiety about
gaining weight. Individuals with BN have an intense preoccupation with food and
their weight. They differ from people who suffer from Anorexia Nervosa (AN) as
they are not striving to be thin, the driving force in AN. Most individuals
with BN have normal weight. In this knol, when we refer to “Bulimia” we are
referring to Bulimia Nervosa (BN).
While bulimia typically affects
females, increasing numbers of males are being diagnosed. Additionally, while
patients tend to be adolescents and young adults, increasingly there are adults
presenting with this disorder. The mean age of onset of the disorder is 18
years of age. In the United States, persons suffering from bulimia are from all
different races and ethnicities.
Several studies have documented
large numbers of late adolescents and young adults with binge eating or purging
behaviors – up to 15% of adolescents and 23% of young adults females, and 14%
of young adult males. Most of these individuals while engaging in unhealthy
behaviors do not meet the diagnosis of BN. This diagnosis is made based on the
criteria of the Diagnostic and Statistical Manual (DSM-IV) (see below).
Physical effects
Bulimia Nervosa is a complex
mental health disorder with significant physiological effects. Most of the
physical effects are due to either binging, with the excessive intake of
calories and fluids, excessive exercise, and/or fasting as a mechanism to deal with
the intake of large amounts of calories, or purging through self–induced
vomiting, or use of diuretics, ipecac, laxatives, or enemas. Often patients may
engage in a number of these activities either simultaneously or consecutively.
Serious physical effects result from cycles of over-eating and purging, which may occur several times a week or may occur more frequently if the individual is seriously impaired.
The effects may include:
• Skin changes, including calluses on the back of the hand
secondary to abrasions from the teeth when the fingers are used to induce
vomiting. Clinicians will call this physical sign the Russell’s sign.
• Swelling of the face and cheeks, including the lower eyelids,
due to increased pressure of blood in the face during vomiting.
Possible complications the
noted systems are :
• Fluids and electrolytes, including:
o dehydration
o low potassium levels
o low sodium levels
o low phosphorous
o swelling of the hands and feet
• The heart, including:
o arrhythmias
o enlargement and damage to the muscles of the heart, secondary
to the use of ipecac
o Changes in blood pressure – low blood pressure
o The lungs/respiratory system, including:
aspiration pneumonia secondary
to vomiting
air in the mediastinum
secondary to vomiting
• The gastrointestinal system, including:
o swelling of the salivary glands
o acid reflux
o swelling of the stomach, due to large amount of food intake,
which may lead to perforation
o tears in the esophagus from persistent vomiting
o slowing in the time it takes for the stomach to empty
o damage to the liver
o pancreatitis
o bloody diarrhea
• the endocrine system, including:
o amenorrhea (periods stopping in females)
Psychological effects
Some behavioral symptoms may
include:
• depressive symptoms
• substance abuse
• lack of impulse control, including cutting, shoplifting,
stealing, and other risky behaviors.
• being overly concerned with food, weight, and body shape
• eating in secret, hoarding and hiding of food
• social isolation, particularly around meals, including avoiding
meals with family and friends
Bulimia Nervosa: Criteria For
Diagnosis
There is no single blood test
or study that a clinician can use to diagnose Bulimia Nervosa; rather BN should
be suspected any time an older adolescent/young adult has significant
fluctuations in their weight. Other medical conditions that need to be ruled
out include a range of gastrointestinal illnesses (e.g., gastroesophageal
reflux disease, gall bladder disease, ulcers), malignancies including those of
the central nervous system, and pregnancy. See Table 1 for differential
diagnosis for BN.
BN is diagnosed using a number
of clinical criteria. The criteria for BN are listed in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV):[2]
1. Recurrent episodes of binge
eating. An episode of binge eating is characterized by both of the following:
a. Eating, in a discrete period
of time (e.g., within any 2-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.
b. 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).
2. Recurrent inappropriate
compensatory behavior to prevent weight gain, such as self-induced vomiting;
misuse of laxatives, diuretics, enemas, or other medications; fasting; or
excessive exercise.
3. The binge eating and
inappropriate compensatory behaviors both occur, on average, at least twice a
week for 3 months
4. Self-evaluation is unduly
influenced by body shape and weight.
5. The disturbance does not
occur exclusively during episodes of Anorexia Nervosa.
There are two subtypes of BN
that have been identified:
1. Purging type: During the
current episode of Bulimia Nervosa, the person has regularly engaged in
self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
2. Nonpurging type: During the
current episode of Bulimia Nervosa, the person has used other inappropriate
compensatory behaviors, such as fasting or excessive exercise, but has not
regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics,
or enemas.
Patients who meet the criteria
for Anorexia Nervosa, but who also binge and purge, will be diagnosed with
Anorexia Nervosa, binge/eating purge subtype not Bulimia Nervosa. (See Anorexia
Nervosa knol)
Many patients may fulfill some
of the criteria for Bulimia Nervosa but not all of them. They still may
struggle with problems with eating and/or problems with body image and weight
maintenance. They may receive a diagnosis of a “partial eating disorder” or
eating disorder not otherwise specified (ED-NOS).
The criteria for Eating
Disorder NOS according to the DSM IV include:
1. meeting all the criteria for
Anorexia Nervosa; however still have normal periods
2. meeting all the criteria for
Anorexia Nervosa, however their weight is still within a normal range.
3. meeting all the criteria for
Anorexia Nervosa; however maintain a normal body image.
4. meeting all the criteria for
Bulimia Nervosa; however the frequency of binging and purging is less than that
specified by the DSM IV necessary to make a diagnosis of Bulimia Nervosa.
5. repeatedly chewing and
spitting out food, but not swallowing
6. binge-eat cycle but without
purging (also known as Binge Eating Disorder)
Despite a difference in the
diagnosis, the treatments are similar, as those who suffer from Anorexia
Nervosa, Bulimia Nervosa, and Eating Disorder-NOS all share a pre-occupation
with food, as well as with body weight and shape.
What Causes Bulimia Nervosa
The exact cause of Bulimia
Nervosa is unknown, but there are believed to be several factors that may lead
to its development. These include biological and genetic factors, psychological
factors, and socio-cultural influences.[1] Eating disorders, including Bulimia
Nervosa run in families, with higher rates among females with identical twins
and/or first-degree relatives with eating disorders. Psychological factors that
have been shown to be associated with bulimia include depression, anxiety, low
self-esteem, personality disorders, disturbances in social functioning (e.g.,
the lack of ability to have meaningful interpersonal relationships resulting in
isolation from normal daily events), substance abuse, and suicidal behavior.
There appears to be an association between sexual/physical abuse and BN. Those
adolescents presenting with BN may often report that they were overweight at
the time they started binging and purging. Individuals with BN tend to come
from more disorganized and conflictive families.
How Do You Treat Bulimia
Nervosa
One of the keys to successful
treatment of bulimia is early recognition of the problem and early
intervention. Adolescents and young adults must be weighed and measured at
every medical appointment, or at a minimum once a year. A Body Mass Index (BMI)
should be calculated and plotted on a growth curve appropriate for the
adolescent’s age and gender. BMI is a tool to screen a person’s nutritional
status and is calculated by taking the weight in kilograms and dividing by the
height (in meters) squared (BMI = kg/m2)
[3],[4] Given that most individuals with BN will be of normal weight,
history of binging and purging episodes is critical for establishing the
diagnosis. Many adolescents and young adults with BN often have had the
disorder for a long period of time before it is discovered, because it is
relatively easy to hide. BN rarely presents prior to the age of 14 years. The
warning signs (listed below) maybe what a parent notices, such as the patient
consuming a notably larger amount of food in a short period of time, or quickly
making a trip to the bathroom or shower following eating.
MultiDisciplinary Treatment
Team
Successful treatment typically
requires a multidisciplinary team knowledgeable in the care of patients with
eating disorders. The team should include:
• A physician who is skilled and comfortable in handling eating
disorders can monitor weight, vital signs, and other health consequences due to
binging and purging. This may be a pediatrician or internist, or may require
referral to an adolescent medicine specialist;
• A dietician or nutritionist who has experience in managing
patients with eating disorders can assist with meal planning, and weight
stabilization; and
• A therapist who is knowledgeable about treating eating
disorders – specifically BN
Goals of treatment
The goals of treatment include
medical, nutritional, and psychological interventions. In treatment of BN, the
critical first step is decreasing the frequency of the binging and purging
episodes.
Medical monitoring is important
initially to make certain the patient’s electrolytes are normalized. Low
potassium levels, due to purging, can lead to cardiac arrhythmias and sudden
death, therefore it is important to monitor these closely.
Nutritional treatment typically
occurs with the guidance of a nutritionist. The goal is to resume healthy
eating habits and patterns. Patients should be encouraged not to skip meals, as
this may frequently trigger binging later in the day. A nutritionist may
develop a meal plan for a patient to ensure they are obtaining optimal calories
in addition to resuming well-balanced eating habits. Patients frequently will
need to be encouraged to avoid foods that “trigger” binging behaviors.
“Trigger” foods vary by individual patients, however may include sugary,
carbohydrates, high fat foods or other foods that the patient may consider
“unhealthy”. Patients will typically need to increase the variation in the
types of food they are eating. Setting realistic weight goals may also be
important.
Other important aspects of
treatment for bulimia include encouraging regular and moderate physical
activity. Regular dental care is important as recurrent self-induced vomiting
may cause dental erosions and caries.
Psychological treatment first
involves establishing the appropriate aims to improve the patient’s body
distortion from over-evaluation of her shape and intense fear of becoming fat,
in addition to symptoms of anxiety and or depression that may also exist.
Beyond anxiety and depressive symptoms, patients struggling with BN frequently
have tremendous shame about their secretive behavior. Other mental health
disorders must be considered, including substance abuse, which needs to be
treated concurrently with BN.
For adolescents and adults with
BN, cognitive-behavioral therapy (CBT) and /or treatment with selective
serotonin reuptake inhibitors (SSRIs) have been demonstrated to be effective.
CBT targets thoughts, feelings, and behaviors in order to break the binge/purge
cycle. In addition, CBT typically includes teaching patients alternate coping
skills for anxiety and depressive symptoms. Increasingly, there is a trend to
encouraging family therapy in addition to CBT and SSRIs.
Antidepressant medications,
particularly selective serotonin reuptake inhibitors have been demonstrated to
be effective either alone or in combination with CBT. Individuals who have
other mental health disorders may need other psychotropic medications or
psychotherapy. Chronic binging and purging may worsen symptoms of anxiety,
depression, and obsessive behavior. It is important to reevaluate symptoms
throughout the treatment and recovery process.
Treatment may require inpatient
hospitalization for medical stabilization. Typically, treatment occurs as an
outpatient. At times, an intensive outpatient or partial hospitalization may be
more beneficial. For patients who are not responding to outpatient treatment
but who are medically stable, residential treatment programs may be necessary.
Multiple residential programs exist across the United States and typically may
benefit those with severe disease who have required previous medical and/or
psychological hospitalization and are continuing to struggle.
Long Term Outcomes
Generally, adolescents have
better outcomes than adults, which may be due to a shorter length of symptoms
among adolescents. Fifty percent of adolescents are thought to fully recover from
BN; however, recovery can take many years with a fluctuating course.[5] Studies
have shown that the full recovery rate for bulimia is significantly higher than
that for Anorexia Nervosa.[6] Given that BN is often associated with other
mental health disorders, it is critical for individuals suffering from this
disorder to get treatment from a mental health professional.
Mortality associated with
Bulimia Nervosa is significantly less than that due to Anorexia Nervosa, but
further research and data are necessary.
Warning Signs of Bulimia
Nervosa
• someone who has a history of anorexia
• someone who is consistently losing or gaining weight in a
relatively short period of time.
• someone who is not gaining weight in a reasonable and expected
manner as they go through puberty
• someone who is using laxatives and other colonic cleansers
• someone who is making frequent trips to the bathroom,
particularly immediately following eating
• disappearance of food, or indications that a large amount of
food was consumed, including empty food wrappers or containers
• someone who has dental caries and erosion
• someone who has made previous suicide attempts
• someone who is skipping meals
• someone who is making frequent excuses for not eating-“I’m not
hungry, I’m too busy, I don’t eat that…” and then eating alone or in secret
• someone who is complaining frequently of feeling cold, when
others do not
• someone who socially withdraws from activities, particularly
activities around food (like going out for dinner or eating with their family)
• someone who repeatedly weighs themselves
• someone who is engaging in prolonged periods of exercise, even
when feel tired or weak
Promoting good eating habits
and a positive body image
1. Parents should be good role
models for their children, with health, eating, and exercise habits
2. Don’t diet-have healthy and
nutritious eating habits
3. Don’t make negative comments
about your own body or anyone else’s
4. Recognize that there are a
range of body shapes and sizes
5. Don’t judge a person based
on their weight or size, it does not reflect the type of person they are
6. Encourage family meals
7. Encourage regular healthy
exercise
Bulimia and the Internet
The majority of Web sites
provide a medical view of bulimia, which defines bulimia as a mental health
disorder that can be cured. These Web sites and online communities are run by
professionals in addition to those suffering with an eating disorder or a
history of an eating disorder. These sites may provide information and support
to current sufferers and their friends and family.
Additionally, there is another
group of Web sites that argue that eating disorders, including both Anorexia
Nervosa and Bulimia Nervosa, are not illnesses but rather a “lifestyle choice.”
These pro-anorexia or pro-ana or pro-mia Web sites may contain dangerous and
unhealthy information including weight-loss tips and support of the
perpetuation of eating disorders. The impact of these sites is unclear, however
they may foster the development of an eating disorder in a vulnerable
adolescent or young adult.
Similarities and Differences:
AN vs BN
AN and BN are both classified
as eating disorders, however there are both similarities and differences
between the two. Table 2 compares the disorders and how they differ.
When to seek medical advice
If you are concerned that you
may have an eating disorder, see your doctor and express your concerns. Often
the bulimia can be so strong, you may resist getting help. Try to find support
from a friend or family member to assist you in finding treatment options.
A major challenge in the
treatment of bulimia, which makes it different from other disorders, is that it
often goes unrecognized because individuals generally are of normal weight and
they feel tremendous shame about acknowledging their health problem. If you
believe someone you know may have an eating disorder, listen