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Bulimia Nervosa: Symptoms, Causes, Treatment and Prevention

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Bulimia nervosa is an eating disorder that is potentially life threatening. It is defined as episodes of binge eating followed by inappropriate response behaviors such as self-induced vomiting; fasting; misuse of laxatives, diuretics or other medicines; or excessive exercise. Individuals with bulimia nervosa judge themselves overly harshly based on perceived body shape and/or weight.

Bulimia nervosa

Who gets bulimia nervosa?

Bulimia nervosa tends to peak in late in adolescence or in early adulthood, but has been diagnosed in children as young as 5 years old and during the geriatric years. It can occur in people of any age, sex, race, gender, ethnicity, economic status, as well as individuals of all body weights, shapes and sizes. Bulimia tends to affect females more often than males. Between 1% and 4% of people will experience bulimia sometime during their lifetime.

People with bulimia may be of low weight, normal weight, or overweight. In all cases, they are dissatisfied with their weight or shape.

What’s the difference between bulimia nervosa and other eating disorders?

People with bulimia often perform their binge-purge behaviors in secret, feeling ashamed of their binges and purges. They are aware they have a problem. This shame and guilt may lead individuals not to seek medical care. In contrast, people with anorexia nervosa may deny or not recognize that they have a problem. Someone may have anorexia nervosa and still binge and/or purge. The difference is that with bulimia nervosa, the behaviors are recognized as a problem and restricting food is not the main behavior. Bulimia nervosa is defined by the binges followed by some form of purge. Binge eating disorder, on the other hand, is limited to the binge behavior.

What causes bulimia nervosa?

The exact cause of bulimia is not known. However, research suggests that it may be a combination of genetic or biologic factors (inherited; runs in families) combined with learned behaviors and thought patterns.

What are the signs and symptoms of bulimia nervosa?

Behavioral and emotional symptoms of bulimia include:

  • Eating more than an expected amount.
  • Frequent visits to the bathroom, particularly after meals.
  • Vomiting or abusing laxatives, diuretics or other medicines in an attempt to prevent weight gain.
  • Excessive exercising or extreme physical training.
  • Preoccupation with body image.
  • An intense fear of gaining weight.
  • Depression or mood swings.
  • Feeling out of control.
  • Feeling guilty or shameful about eating.
  • Withdrawing socially from friends and family.
  • Lack of awareness of the seriousness of the condition.

Physical symptoms of bulimia nervosa include:

  • Facial swelling or swollen parotid glands visible at the jawline or cheeks (parotitis).
  • Heartburn, indigestion, bloating.
  • Irregular menstrual periods.
  • Weakness, exhaustion.
  • Bloodshot eyes.
  • Dental problems, including erosion of tooth enamel.
  • Sore throat.
  • Petechiaie (pinpoint bruising) on the back of the pharyngeal wall (back of throat).
  • Bleeding gums.
  • Thickening (callus) or scratches (excoriations) on the back of the knuckles (Russell sign).
  • Sores at the angle of the mouth on either side.

What complications are associated with bulimia nervosa?

  • Erosion of tooth enamel because of repeated exposure to acidic gastric contents.
  • Dental cavities.
  • Tooth sensitivity to hot or cold food.
  • Swelling and soreness in the salivary glands (from repeated vomiting).
  • Stomach ulcers.
  • Tears in the lining of the stomach and esophagus.
  • Constipation.
  • Electrolyte imbalance (chloride, potassium other chemical levels) outside normal level range.
  • Dehydration.
  • Irregular heartbeat and abnormal heart rhythms.
  • Heart attack (in severe cases).
  • Sudden cardiac death.
  • Higher risk for suicidal behavior.

How is bulimia nervosa diagnosed?

Your doctor will perform a complete medical history and physical examination. He or she will ask you about your diet – what and how much you eat. The doctor will ask about binge and purging frequency and elimination habits (vomiting, use of laxatives/diuretics, fasting, exercise regimen). Your current medications will also be reviewed. The doctor will also ask about family history of eating disorders, substance abuse and psychological disorders (suicidal thoughts).

Although there are no laboratory tests to specifically diagnose bulimia, the doctor might use various diagnostic tests, including laboratory values (a blood test), to evaluate the severity of illness or the effects bulimia on the body’s organs. The doctor may order an electrocardiogram (ECG) to check for slow heart rate, chest pain, abnormal heart rhythm, or heart flutter.

To be diagnosed with bulimia nervosa, the doctor will determine if these criteria have been met:

  • Does the person have repeating episodes of binge eating? Binge eating is defined as eating a larger amount of food than most other people would eat in a similar time period under similar circumstances.
  • Does the person feel they lack control over eating during an episode; they cannot control what or how much they are eating?
  • Does the person engage in inappropriate behaviors to prevent weight gain, including self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting or excessive exercise?
  • Has the binge-purge behavior occurred at least once a week for 3 months?
  • Does the person’s body weight or shape have a strong influence on their self-image?

If all of the criteria are met, but the binges and/or purging behaviors have not been going on at least weekly for three months, the person may have “subclinical bulimia nervosa,” meaning they are still at risk, but the time criteria has not yet been met.

How is bulimia treated?

The goal of treatment is to break the pattern of binge-purge behavior, correct distorted thinking patterns, and develop long-term behavioral changes. Your treatment team may consist of medical doctors, dietitians, and mental health professionals.

Typical treatment consists of medications plus psychological counseling and nutritional counseling. Medications common used include selective serotonin reuptake inhibitors such fluoxetine (Prozac®) or sertraline (Zoloft®); atypical neuroleptics such as olanzapine (Zyprexa®) and serotonin-norepinephrine reuptake inhibitors. Tricycylic antidepressants are less likely to be used as they may cause cardiac rhythm abnormalities

Psychological counseling is a type of individual counseling that focuses on changing the thinking (cognitive therapy) and behavior (behavioral therapy) of a person with an eating disorder. Treatment includes practical techniques for developing healthy attitudes toward food and weight, as well as approaches for changing the way the person responds to difficult situations. Three types of psychotherapy are thought to be the most helpful for treating bulimia. These are:

  • Cognitive Behavioral Therapy (CBT). This therapy’s goal is to address distorted views and attitudes about weight, shape and appearance and practice behavioral modification (if “X” happens, I can do “Y” instead of “Z”).
  • Dialectical Behavior Therapy (DBT), is CBT plus insight. In other words, this therapy helps the individual not just develop new skills to handle negative triggers, but also helps the person develop insight to recognize triggers or situations where a non-useful behavior might occur. Specific skills include building mindfulness, improving relationships through interpersonal effectiveness, managing emotions and tolerating stress.
  • Family-based Treatment (also called the Maudsley Method). This therapy involves family-based feeding, which means putting the parents/family in charge of getting the appropriate nutritional intake consumed by the individual with the eating disorder. FBT has shown more efficacy with anorexia nervosa at this time, with studies ongoing.

Nutrition counseling involves learning healthier way to eat under the guidance of a registered dietitian or counselor.

Can bulimia nervosa be prevented?

Because the true reason for the development of bulimia is not known, it is difficult to say how bulimia can be prevented. However, educators and parents can help young people understand that the “ideal” body type portrayed by the media is far from realistic and can be unhealthy and even unsafe.

What is the outlook for people with bulimia nervosa?

Many individuals with bulimia get better with treatment. Some individuals improve at first but then relapse and need treatment again. Statistics show that approximately half of all persons with bulimia will fully recover with appropriate treatment, another 30% will experience a partial recovery and 10% to 20% will continue to battle symptoms.

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