Bulimia nervosa

Bulimia nervosa
Specialty	Psychiatry

Bulimia nervosa is an eating disorder characterized by recurrent binge eating, followed by compensatory behaviors. The most common form—practiced by more than 75% of people with bulimia nervosa—is self-induced vomiting, sometimes called purging; fasting, the use of laxatives, enemas, diuretics, and over exercising are also common. The word bulimia derives from the Latin (būlīmia) from the Greek βουλῑμια (boulīmia; ravenous hunger), a compound of βους (bous), ox + λῑμος (līmos), hunger.

Bulimia nervosa was named and first described by the British psychiatrist Gerald Russell in 1979.

Diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) published by the American Psychiatric Association, the criteria for diagnosing a patient with bulimia are:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a fixed period of time, an amount of food that is definitely larger than most people would eat under similar circumstances.
  • A lack of control over eating during the episode: a feeling that one cannot stop eating or control what or how much one is eating.
• Recurrent inappropriate compensatory behavior to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; excessive exercise.
• Self-evaluation is unduly influenced by body shape and weight.
• These symptoms occur at least twice a week on average and persist for at least 3 months.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

There are two sub-types of bulimia nervosa:

• Purging type bulimics self-induce vomiting (usually by triggering the gag reflex or ingesting emetics such as syrup of ipecac) to rapidly remove food from the body before it can be digested, such as laxatives, diuretics, and enemas.
• Non-purging type bulimics (approximately 6%-8% of cases) exercise or fast excessively after a binge to offset the caloric intake after eating. Purging-type bulimics may also exercise or fast, but as a secondary form of weight control.

The onset of bulimia nervosa is often during adolescence (between 13 and 20 years of age), with many sufferers relapsing in adulthood into episodic binging and purging even after initially successful treatment and remission.

Bulimia nervosa can be difficult to detect, compared to anorexia nervosa, because bulimics tend to be of average or slightly above or below average weight. Many bulimics may also engage in significantly disordered eating and exercising patterns without meeting the full diagnostic criteria for bulimia nervosa.

Prevalence

There is little data on the prevalence of bulimia nervosa in-the-large, on general populations. Most studies conducted thus far have been on convenience samples from hospital patients, high school or university students. These have yielded a wide range of results: between 0.1% and 1.4% of males, and between 0.3% and 9.4% of females. Studies on time trends in the prevalence of bulimia nervosa have also yielded inconsistent results.

Country	Year	Sample size and type	Incidence
Australia	2008	1943 adolescents (ages 15–17)	1.4% male	9.4% female
Portugal	2006	2028 high school students		0.3% female
Brazil	2004	1807 students (ages 7–19)	0.8% male	1.3% female
Spain	2004	2509 female adolescents (ages 13–22)		1.4% female
Hungary	2003	580 Budapest residents	0.4% male	3.6% female
Australia	1998	4200 high school students	0.3% combined
USA	1996	1152 college students	0.2% male	1.3% female
Norway	1995	19067 psychiatric patients	0.7% male	7.3% female
Canada	1995	8116 (random sample)	0.1% male	1.1% female
Japan	1995	2597 high school students	0.7% male	1.9% female
USA	1992	799 college students	0.4% male	5.1% female

There are higher rates of eating disorders in groups involved in activities which idealize a slim physique, such as dance, gymnastics, modeling, cheerleading, running, acting, rowing and figure skating. Bulimia is more prevalent among Caucasians.

Effects

These cycles often involve rapid and out-of-control eating, which may stop when the bulimic is interrupted by another person or the stomach hurts from overextension, followed by self-induced vomiting or other forms of purging. This cycle may be repeated several times a week or, in more serious cases, several times a day, and may directly cause:

• Chronic gastric reflux after eating
• Dehydration and hypokalemia caused by frequent vomiting
• Electrolyte imbalance, which can lead to cardiac arrhythmia, cardiac arrest, and even death
• Esophagitis, or inflammation of the esophagus
• Oral trauma, in which repetitive insertion of fingers or other objects causes lacerations to the lining of the mouth or throat
• Gastroparesis or delayed emptying
• Constipation
• Enlarged glands in the neck, under the jaw line
• Peptic ulcers
• Calluses or scars on back of hands due to repeated trauma from incisors

The frequent contact between teeth and gastric acid, in particular, may cause:

• Severe caries
• Perimolysis, or the erosion of tooth enamel
• Swollen salivary glands

Related disorders

Bulimics are much more likely than non-bulimics to have an affective disorder, such as depression or general anxiety disorder: A 1985 Columbia University study on female bulimics at New York State Psychiatric Institute found 70% had suffered depression some time in their lives (as opposed to 25.8% for adult females in a control sample from the general population), rising to 88% for all affective disorders combined. Another study by the Royal Children's Hospital in Melbourne on a cohort of 2000 adolescents similarly found that those meeting at least two of the DSM-IV criteria for bulimia nervosa or anorexia nervosa had a sixfold increase in risk of anxiety and a doubling of risk for substance dependency. Bulimia also has negative effects on the sufferer's dental health due to the acid passed through the mouth from frequent vomitting causing acid erosion, mainly on the posterior dental surface.

Treatment

There has been no single, consistently-effective therapy for bulimia nervosa.

Pharmacological

Some researchers have hypothesized a relationship to mood disorders and clinical trials have been conducted with tricyclic antidepressants, MAO inhibitors, mianserin, fluoxetine, lithium carbonate, nomifensine, trazodone, and bupropion.

Research groups who have seen a relationship to seizure disorders have attempted treatment with phenytoin, carbamazepine, and valproic acid. Opiate antagonists naloxone and naltrexone, which block cravings for gambling, have also been used.

There has also been some research characterizing bulimia nervosa as an addiction disorder, and limited clinical use of topiramate, which blocks cravings for opiates, cocaine, alcohol and food. Researchers have also report positive outcomes when bulimics are treated in an addiction-disorders inpatient unit,

Psychotherapy

There are several empirically-supported psychosocial treatments for bulimia nervosa. Cognitive behavioral therapy (CBT), which involves teaching clients to challenge automatic thoughts and engage in behavioral experiments (e.g., in session eating of "forbidden foods") has demonstrated efficacy both with and without concurrent antidepressant medication.. Researchers have also reported some positive outcomes for interpersonal psychotherapy and dialectical behavior therapy.

Some researchers have also claimed positive outcomes in hypotherapy treatment.

In popular culture

In April 2008, former British Deputy Prime Minister John Prescott revealed he became bulimic during the stress of his first years as deputy prime minister.

Princess Diana admitted to suffering for years with bulimia.