Bulimia Nervosa

What is bulimia nervosa?

Although this eating disorder is less well-known than anorexia nervosa, bulimia nervosa is actually more common among American teenage and young women -- and just as serious.

Bulimia nervosa, or simply "bulimia," is often referred to as "bingeing and purging." In other words, people with this eating disorder go on wild eating binges, consuming between 1,000 and 20,000 calories in one sitting (usually in the form of high-calorie foods such as ice cream or pies). They then purge what they've eaten by vomiting or taking laxatives or diuretics before their bodies can absorb the food. In many cases, they follow up binges not by purging but with periods of excessive exercising or fasting.

Bulimia is a serious illness that can have grave consequences if not treated, including stomach ruptures, heart problems, and even death.

Yet bulimics will go to great lengths to hide this disorder from their friends and family. They'll binge in private, get rid of the candy wrappers or other evidence of their binge, and often run water in the bathroom sink to cover the noise of their vomiting. This is why it's important for family, friends and doctors to be aware of the symptoms of bulimia and know how to offer help.

Experts estimate that some 2 to 3 percent of teenage girls and young women suffer from bulimia. Though it's less common in males, up to 15 percent of bulimia sufferers are thought to be boys and young men. Bulimia tends to peak in late adolescence and early adulthood.

Bulimia is closely related to anorexia, an illness in which people starve themselves. Unlike anorexics, however, few patients with bulimia look emaciated or starved, so it may be more difficult to realize that someone has this eating disorder.

Are there different kinds of bulimia?

Experts have defined two types of bulimia: purging, characterized by vomiting or use of laxatives, diuretics or enemas to counteract the effects of bingeing, and non-purging, in which periods of excessive exercise or fasting follow binges. (Nonpurging bulimic behavior is similar to anorexic behavior.) Sufferers may alternate between the two types.

What causes bulimia?

No one really knows exactly what causes eating disorders -- including bulimia -- but research indicates that several factors probably contribute to their development. These include personality traits (bulimics, for example, tend to be depressed and have low self-esteem) and the home environment (bulimics often come from families in which rules are chaotic or non-existent, alcohol or substance abuse is common, and great emphasis is placed on looks). Societal influences, such the pressure on women to be thin or even underweight, are also thought to play an important role.

Bulimics' bingeing episodes, which almost always take place in secret, are often triggered by stress or emotional problems. Purging is thought to serve two purposes for bulimics: It both keeps them from gaining weight and gets rid of negative feelings, such as anger, that they've learned to associate with food.

Many bulimic patients say they felt deprived of affection as children, and psychologists believe they may binge in an attempt to physically fill the void of emotional hunger, loneliness, and feelings of inadequacy. Often bulimics say they feel they have no control over their eating habits or their lives in general -- a state of mind reflected in other out-of-control behaviors sometimes associated with the disease, such as drug or alcohol abuse, spending sprees, and shoplifting.

Frequently, but not always, people with eating disorders have been victims of sexual, physical or emotional abuse as children. Some recent studies, however, have shown that bulimics haven't experienced childhood sexual abuse more than other women who are depressed or anxious, according to the Harvard Mental Health Letter.

What is a typical bulimic like?

Bulimia can take many forms. The following profile is based on psychological and physical traits common among young women who have bulimia, but you or someone you love can have the eating disorder even without fitting this profile.

The typical bulimic is around 19, has a normal or slightly above-normal weight, and is often rebellious and depressed. She's obsessed with her weight and judges herself harshly based on her body shape. She tries to hide both her bingeing and purging activities from friends and family. She may seem out of control in other areas of her life, perhaps abusing alcohol or shoplifting. She probably knows something is wrong with her and feels a great deal of shame and guilt about her eating habits.

What are the symptoms?

Bulimia nervosa may be difficult to recognize because the sufferer tries hard to hide her disease. She will binge in private, lie about what she eats, and take care to purge secretly. But it's important to learn to stop symptoms of bulimia -- the longer a person has the disease, the harder it is to cure, so sufferers need to get help as soon as possible.

Dentists are often the first to suspect bulimia, because gastric (stomach) acid from frequent, induced vomiting can damage tooth enamel and gums.

Other telling signs include:

• Eating binges
• Frequent use of the bathroom after meals, with water turned on to cover the noise of vomiting
• Overuse of laxatives or diuretics
• Obsessive concern about weight
• Compulsive exercising
• Strict dieting or fasting
• Attempting and failing at many diets
• Weight fluctuation (repeated gains and losses of more than 10 pounds)
• Feelings of guilt or shame about eating
• Frequent depression
• Overeating in response to emotional stress
• Irregular or missed periods
• Signs of dehydration (dark urine, sticky saliva, fatigue) and weakness
• Swollen salivary glands

What can I do if someone I care about is bulimic?

Confronting someone you think is bulimic can be tricky -- she may deny that she's sick or feel horribly ashamed that you have discovered her secret. It must be done, however, and the sooner the better.

Experts recommend that you first learn everything you can about the disease. Then pick a good time to talk, perhaps when the two of you are alone and free of distractions, and tell her in a non-judgmental way that you are concerned and would like her to seek help. Cite specific examples of her behavior that let her know you know what you're talking about -- for instance, that you've noticed she always goes to the bathroom after eating and you've smelled vomit there afterward.

Be prepared for her to be ashamed of her disease and deny that she has a problem. Be sensitive to her feelings and avoid getting into an argument. Do not try to cure this illness yourself: If your loved one has bulimia, she needs professional treatment.

If you are her parent and are able to, take her to a doctor for a physical and ask the doctor to talk to her as well. A doctor can make a referral to a mental health professional if he or she thinks your child is at risk.

If you're a friend or relative, be supportive and let the bulimia sufferer know that you remain concerned about her. Continue to offer support, and volunteer to make appointments with counselors for her or get information about support groups in her area. You may want to contact her family if you think she is in danger.

Avoid making comments (positive or negative) about weight gain or loss, as these could reinforce her disease. Don't try to solve her problem for her: This is a dangerous and complex illness. Be aware of any physical deterioration and get professional help for her as soon as possible.

Finally, don't forget to take care of yourself. This disease is hard on family and friends as well. Look into joining a support group where you can talk about your feelings.

How is bulimia diagnosed?

Doctors will diagnose someone as bulimic if she has binged compulsively at least once a week for three months, but some feel this definition is too narrow. Many bulimics, for example, will alternate periods of normal eating, or dieting or fasting, with binge episodes. To better determine whether the patient has an eating disorder, a doctor will ask her how she feels about weight and obesity (bulimics have an extreme fear of being fat) and if she has been dieting and losing or gaining weight. The doctor will also do a complete check up to look for any physical damage bulimia may have caused, such as electrolyte imbalances, dehydration, tooth damage, throat scarring, and heart problems.

How does bulimia differ from anorexia?

The two diseases are related but have some telltale differences. While anorexics are usually underweight, bulimics are usually normal weight or slightly overweight. Bulimia peaks later than anorexia, during late adolescence or early 20s. And people with bulimia tend to be aware (and ashamed) of their illness, while people with anorexia often don't realize that they're sick.

Experts say that about 25 percent of people with bulimia also have had anorexia; likewise, about half of those with anorexia are thought to become bulimic at some point.

What kinds of treatments are available?

Treatment for bulimia depends largely on the individual and the seriousness of the disorder. Most bulimics can be treated successfully on an outpatient basis by a team of health care providers, including a primary care doctor, psychiatrist, psychotherapist and a registered dietician.

If the patient has severe medical complications, such as dehydration, irregular heartbeat, or infections, she may need inpatient services or those of an endocrinologist or a surgeon. In particular, signs of gastric obstruction (uncontrollable vomiting or continuous projectile vomiting after food intake) require emergency consultation and/or treatment.

An antidepressant such as fluoxetine (Prozac) is commonly prescribed for bulimia. This, in combination with nutrition counseling and cognitive-behavioral therapy -- and sometimes long-term psychotherapy that deals with questions of body image and self-esteem-- is considered the most effective treatment for bulimia. Because bulimia is a complex disease, experts advise a therapist who specializes in eating disorders. Family therapy may also be necessary for younger patients, or for those still living at home.

What could happen if bulimia goes untreated?

Bulimia can cause serious health problems, ranging from esophagus and tooth damage (from vomiting) to kidney and heart problems, dehydration, an overall loss of energy, and even death

In rare cases, bulimia can cause the stomach or esophagus to rupture, which in turn can cause hemorrhaging and death. Fluid and electrolyte imbalances caused by purging can lead to an irregular heartbeat, which in turn may lead to more serious heart conditions.

Some people with bulimia abuse laxatives which can cause long-lasting digestive and bowel problems.

The mortality rate for eating disorders, including anorexia, may be as high as 20 percent, taking into account deaths from related heart and intestinal damage and suicide.

Further Resources

The National Association of Anorexia Nervosa and Associated Disorders can mail information as well as refer callers to experts and support groups in their area. P.O. Box 7, Highland Park, IL 60035 (847) 831-3438

The National Eating Disorders Association, can also mail information and refer callers to experts and support groups in their area. (206) 382-3587

References

Mayo Clinic. Bulimia nervosa. http://www.mayoclinic.com/health/bulimia/DS00607

National Alliance on Mental Illness. Bulimia Nervosa. http://www.nami.org/Content/ContentGroups/Helpline1/Bulimia.htm

Bulimia Nervosa. DSM-V. American Psychiatric Association.

Mitchell JE, et al. The relative efficacy of fluoxetine and manual-based self-help in the treatment of outpatients with bulimia nervosa. J Clin Psychopharmacol. Vol. 21(3):298-304.

Grilo CM, et al. Childhood psychological, physical and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology. Obes Res, ; Vol. 9(5):320-5.

Romans SE, et al. Child sexual abuse and later disordered eating: a New Zealand epidemiological study. Int J Eat Disord, Vol. 29(4):380-92.

Raffi AR, et al. Life events and prodromal symptoms in bulimia nervosa. Psychol Med, vol. 30(3):727-31.

Webster JJ, et al. The childhood and family background of women with clinical eating disorders: a comparison with women with major depression and women without psychiatric disorder. Psychol Med;30(1):53-60.

National Women's Health Resource Center. Eating Disorders. http://www.healthywomen.org/healthtopics/eatingdisorders

Pritts S.D. et al. Diagnosis of Eating Disorders in Primary Care. American Family Physician. Vol. 67/No. 2. http://www.aafp.org/afp/20030115/297.html