What is bulimia?

Bulimia, also called bulimia nervosa, is an eating disorder. Bulimia is characterized by episodes of secretive excessive eating (bingeing) followed by inappropriate methods of weight control, such as self-induced vomiting (purging), abuse of laxatives and diuretics, or excessive exercise. Like anorexia, bulimia is a psychological disorder. It is another condition that goes beyond out-of-control dieting. The cycle of overeating and purging can quickly become an obsession similar to an addiction to drugs or other substances. The disorder generally occurs after a variety of unsuccessful attempts at dieting.

Bulimia is estimated to affect between 3% of all women in the U.S. at some point in their lifetime. About 6% of teen girls and 5% of college-aged females are believed to suffer from bulimia. These numbers are somewhat lower than earlier estimates of the prevalence of bulimia due to the precise criteria now established for the diagnosis (see below). Approximately 10% of identified bulimic patients are men. Bulimics are also susceptible to other compulsions, affective disorders, or addictions. Twenty to 40% of women with bulimia also have a history of problems related to drug or alcohol use, suggesting that many affected women may have difficulties with control of behavioral impulses.

Unlike anorexics, bulimics experience significant weight fluctuations, but their weight loss is usually not as severe or obvious as anorexics. The long-term prognosis for bulimics is slightly better than for anorexics, and the recovery rate is felt to be higher. However, many bulimics continue to retain slightly abnormal eating and dieting behaviors even after the recovery period.

The secrecy of bulimia stems from the shame that bulimics often attach to the disorder. Binge eating is not triggered by intense hunger. It is a response to depression, stress, or other feelings related to body weight, shape, or food. Binge eating often brings on a feeling of calm or happiness (euphoria), but the self-loathing because of the overeating soon replaces the short-lived euphoria.

Often, the individual will feel an impairment or loss of control during the binge eating and the purging becomes a way of regaining control. Not all bulimics engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode. Some may fast for days following a binge episode. Others may resort to excessive exercise as a method to regain their control and rid their body of the possible weight gained during the binge. Excessive exercise is that which interferes with normal daily activities or when it occurs at inappropriate times or in inappropriate settings, or when it continues despite illness or injury.

What causes bulimia?

As with anorexia, there is currently no definite known cause of bulimia. Because of the complexity of the disorder, researchers within the medical and psychological fields continue to explore its dynamics.

Bulimia is generally felt to begin with a dissatisfaction of the person's body. The individual may actually be underweight, but when the person looks in a mirror they see a distorted image and feel heavier than they really are. At first, this distorted body image leads to dieting. As the body image in the mirror continues to be seen as larger than it actually is, the dieting escalates and can lead to bulimic practices.

In certain neurological or medical conditions, there can be disturbed eating behavior, but the essential psychological feature of bulimia, the extreme concern with body shape and weight, is not present. For example, overeating is a common feature in depression, however, these individuals do not engage in inappropriate weight-loss behaviors and are not overly concerned with body image and weight loss as is characteristic of the person with bulimia.

Organic causes for bulimia are being investigated. There is evidence that bulimia and other eating disorders may be related to abnormalities in levels of chemical messengers (neurotransmitters) within the brain, specifically the neurotransmitter serotonin. Other studies of people with bulimia have found alterations in metabolic rate, decreased perceptions of satiety, and abnormal neuroendocrine regulation (the process by which the nervous system interacts with production of hormones and hormone-like substances).

How is bulimia diagnosed?

As with anorexia, denial and secrecy complicate the diagnosis of bulimia. The individual usually does not come to the attention of the practitioner until an associated medical condition or serious psychological problem manifests itself. Truthful disclosure of behaviors is critical for an accurate diagnosis. The actual criteria for bulimia nervosa are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). There are five basic criteria in the diagnosis of bulimia:

Recurrent episodes of binge eating. This is characterized by eating within a 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.

A sense of lack of control over the eating during the episode, or a feeling that one cannot stop eating.

In addition to the binge eating, there is an inappropriate compensatory behavior in order to prevent weight gain. These behaviors can include self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, or excessive exercise.

Both the binge eating and the compensatory behaviors must occur at least two times per week for three months and must not occur exclusively during episodes of anorexia.

Finally, there is dissatisfaction with body shape and/or weight.

The DSM-IV also identifies two subtypes of bulimia nervosa. The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. The nonpurging type engages in other inappropriate compensatory behaviors, such as fasting or excessive exercise, rather than purging methods.

What are signs that may suggest a person has bulimia?

It is not always possible to tell whether a person has bulimia. Those affected may be overweight, underweight, or of normal body weight. However, some warning signs may be present, although these do not confirm the diagnosis of bulimia:

going to the bathroom after every meal (to induce vomiting)

compulsive or excessive exercising

physical signs arising from excessive vomiting such as swollen cheeks or jaws, broken blood vessels in the eyes, or teeth that appear clear due to damage to tooth enamel

excessive preoccupation with body image or weight

What medical complications and long-term effects can bulimia have?

The medical complications that result from bulimia are generally due to continual bingeing and purging. The type of purging behavior used can have varied effects on different body systems.

Self-induced vomiting can result in oral complications. Repeated exposure to acidic gastric contents can erode tooth enamel, increase dental cavities, and create a sensitivity to hot or cold food. Swelling and soreness in the salivary glands (such as the parotid glands in the cheeks) from repeated vomiting can also be a concern.

The esophagus and the colon are the areas most affected by bulimic behaviors. Repeated vomiting can result in ulcers, ruptures, or strictures of the esophagus. Acid that backs up from the stomach (reflux) can also become a problem.

As with anorexia nervosa and other eating disorders, irregular menstrual periods or amenorrhea (the absence of menstrual periods) may result from malnutrition or weight fluctuations associated with bulimia.

There are a number of intestinal and systemic complications. The misuse of diuretics can create an abnormal buildup of fluid (edema). Continual use of laxatives can result in dependency on them and can cause the normal elimination process to become dysfunctional. Loss of normal colonic function can necessitate surgical intervention in some cases. Restoration of normal bowel function may take weeks after the misuse has been discontinued. The misuse of diuretics and laxatives combined can place the bulimic at great risk for electrolyte imbalance, which can have life-threatening consequences. The complex physical and chemical processes involved in the maintenance of life can be disrupted with serious consequences by the continuation of bulimic and purging behaviors. Additional complications can affect an unborn fetus of a practicing bulimic or the infant of an active bulimic mother. Psychological problems can escalate to serious levels if untreated and interfere with the restoration of normal body functions.

How is bulimia treated?

Patients with bulimia present a variety of medical and psychological complications which are usually considered to be reversible through a multidisciplinary treatment approach. Treatment can be managed by either a physician, psychiatrist, or in some cases, a clinical psychologist. The extent of the medical complications generally dictates the primary treatment manager. A psychiatrist, with both medical and psychological training, is perhaps the optimum treatment manager.

A number of antidepressant medications have been shown to be beneficial in the treatment of bulimia. Several studies have demonstrated that fluoxetine (Prozac), a member of the selective serotonin reuptake inhibitor (SSRI) class of antidepressants, has been effective in the treatment of bulimia. And the U.S. Food and Drug Administration has approved fluoxetine for the treatment of bulimia.

Other types of antidepressants, including the monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, and buspirone (Buspar) have all been shown to decrease bingeing and vomiting in people suffering from bulimia. However, the SSRIs remain the first choice for treatment due to their relative safety and low incidence of side effects.

Other drugs are currently under investigation as possible treatments for bulimia. Examples are the antiepileptic drug topiramate and the serotonin antagonist ondansetron.

Some patients may require hospitalization due to the extent of the medical or psychological complications. Others may seek outpatient programs. Still others may require only weekly counseling and monitoring by a practitioner. Stabilization of the patient's physical condition will be the immediate goal if the individual is in a life-threatening state. The primary goals of treatment should address both physical and psychological needs of the patient in order to restore physical health and normal eating patterns. The patient needs to identify internal feelings and distorted beliefs that led to the disorder initially. An appropriate treatment approach addresses underlying issues of control, self-perception, and family dynamics. Nutritional education and behavior management provides the patient with healthy alternatives to weight management. Group counseling or support groups can assist the patient in the recovery process as well.

The ultimate goal should be for the patient to accept herself/himself and lead a physically and emotionally healthy life. Restoration of physical and mental health will probably take time, and results will be gradual. Patience is a vital part of the recovery process. A positive attitude coupled with much effort on the part of the affected individual is another integral component to a successful recovery.

Bulimia At A Glance

Bulimia (also called bulimia nervosa) is a psychological eating disorder.

Bulimia is felt to be related to a person's dissatisfaction with their own body image, although the exact cause is not known.

Bulimia is diagnosed according to defined criteria.

There are two types of bulimia: the purging and nonpurging types.

The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

The nonpurging type engages in other inappropriate behaviors such as fasting or excessive exercise, rather than purging.

Bulimia can have serious medical complications.

The successful treatment of bulimia is often multidisciplinary involving both medical and psychological approaches.

The goals of treatment are to restore physical health and normal eating patterns.