Bulimia nervosa: clinical features and treatment approaches

Bulimia is a serious eating disorder, but it does not get the same media coverage or understanding as anorexia. One of the reasons for that is that bulimic patients are typically a normal weight. People around them may not realize they have a problem or that they suffer from disordered eating of any kind. Those who have bulimia are characterized by a cycle of binging on food and then purging through vomiting or the use of laxatives (Hay & Claudino, 2010; Palmer, 2004). Some bulimics also take stimulants or diuretics, and they may exercise excessively (Hay & Claudino, 2010). Because the people around them see them eating relatively normally, they may not realize there are serious physical and psychological issues at play. The bulimic individual, though, generally knows that his or her disordered eating patterns are not normal. Depending on the reasons behind the eating disorder, he or she may not be able to stop the behavior without serious help and intervention from outside sources (Hay & Claudino, 2010; Russell, 2009).

While the majority of bulimics are women, there are also men who have the disorder (Russell, 2009). Some studies indicate that men may be underrepresented as bulimics, and there may actually be many more of them than first thought. They may hide the problem better than women, and they generally are not suspected of having eating disorders (Russell, 2009). That can cause the issue to go unnoticed by friends and family. However, even if the bulimic person appears normal from a weight standpoint, he or she will be doing a lot of damage to esophagus and teeth, along with organs and bodily systems (Palmer, 2004). The binging and purging that comes with bulimia can rob the body of vital, valuable nutrients, and can cause issues with proper growth and development, especially for young people (Palmer, 2004). It is very important that bulimia is caught early, so it can be treated successfully and the patient can move forward with his or her life.

History

People bingeing on food and then vomiting or purging through other means is not something new. Bulimia is talked about more now because it is a recognized disorder, but it has been around since 970 B.C., when there was recorded information about purging done by the ancient Greeks (Patton, et al., 2008). Additionally, ancient Egypt had recommended purging rituals that people were involved in once per month for three days at a time (Patton, et al., 2008). The theory then was that food was what actually caused sickness, and when a person purged in that way it helped to purify the body so the person would not become ill (Hay & Claudino, 2010; Patton, et al., 2008).

Some ancient Roman emperors also commonly purged, as they were obese and gluttonous. Christian saints have some recorded bulimic behaviors, as well. Some of these saints believed that their binging behaviors were the work of the devil, and their purging was their way of repenting for those behaviors (Hay & Claudino, 2010). Several died of starvation because they purged and fasted too long in an effort to repent for their perceived sinful behavior, as treatment for such disorders was not available at that time (Hay & Claudino, 2010; Patton, et al., 2008; Russell, 2009).

It was not until the 20th Century that bulimia -- or, more specifically, bulimia nervosa -- was listed as an actual symptom of disordered eating (Hay & Claudino, 2010). It was not immediately classified as its own disorder at that time. Instead, the purging was seen as a symptom displayed by anorexics, and the cause of the purging was believed to be stomach pain (Palmer, 2004). The 1930s through the 1950s were a time when bulimic behaviors were more commonly seen, but the disorder still had not become "official" in that it was not listed in the Diagnostic and Statistical Manual of Mental Disorders. That made it impossible for anyone during that time to be diagnosed as bulimic, despite having specific characteristics. In 1980, bulimia became a recognized disorder, which led to the diagnosing of a number of cases of it throughout the early part of the 1980s (Hay & Claudino, 2010). The number decreased slightly in the late 1980s, but still remained higher than the number of those diagnosed with anorexia (Russell, 2009).

Signs and Symptoms

There are a number of signs and symptoms of bulimia. The most obvious for diagnostic purposes are binging on food and then purging afterward, but they can also be difficult to spot because many bulimics have learned to hide them relatively well (Russell, 2009). The bingeing comes in the form of eating that is completely out of control and very rapid. It may be stopped because someone else walked in, or it may not stop until the bulimic is in pain from over-extension of the stomach (Russell, 2009). Either way, this binge is usually followed by vomiting which is self-induced (Hay & Claudino, 2010). Some bulimics purge in other ways, but vomiting is the most common (Russell, 2009). This binge-purge cycle often takes place more than once per week. Extreme bulimics may repeat the cycle several times per day (Russell, 2009). There are common signs a bulimic person may exhibit, especially as the bulimia becomes more severe. These include:

An extreme fixation on weight and/or on the number of calories being consumed in any given period.

Bouts of depression.

Low blood pressure.

Trouble with self-esteem and self-worth.

For women, trouble with the menstrual cycle (generally in the form of irregularity).

Frequent (near constant) trips to the bathroom.

Exercise to the point of exhaustion and/or exercise in a very unhealthy manner.

Severe physical symptoms such as muscle weakness, cardiac arrhythmias, and seizures.

Delusions leading to false beliefs (Hay & Claudino, 2010).

Additionally, there are a number of symptoms that can appear when a person is bulimic, and these generally develop and worsen over time. Not every bulimic person will develop all of these symptoms, which typically include:

Dehydration that comes from vomiting frequently.

Imbalances of electrolytes within the body.

Oral trauma that leads to lacerations in the mouth and the severe erosion of the teeth -- up to and including tooth loss.

Damage to the esophagus, including inflammation, acid reflux, acid erosion, and rupture (Hay & Claudino, 2010).

There are also other symptoms of bulimia, such as weight fluctuations, constipation, ulcers, and even infertility (Palmer, 2004). The constant bingeing and purging creates a number of unhealthy conditions and imbalances in numerous bodily systems.

Diagnosis

In order for a person to be diagnosed as bulimic, he or she must meet the official criteria in the most current, recognized version of the Diagnostic and Statistical Manual of Mental Disorders. Many people who develop bulimia do so when they are adolescents, typically between 13 and 20 years of age (Patton, et al., 2008). A number of those who become bulimic were once overweight or obese, and even with successful treatment many of them relapse into binging and purging behavior in adulthood (Patton, et al., 2008). It is believed that nearly one percent of women are bulimic, and that 10 years from diagnosis only half of them will be fully recovered (Patton, et al., 2008). There will be between 10 and 20% who will still have symptoms, and some that will have partially recovered (Patton, et al., 2008).

One of the issues that can lead a person to bulimic tendencies is having a focus on perfectionism and issues with compulsive eating (Hay & Claudino, 2010). To meet the criteria for bulimia, patients must exhibit the bingeing and purging behaviors that come along with it on their own, and not as a subset or facet of any type of anorexia or other eating disorder (Palmer, 2004). A number of people have these tendencies and also have bulimic habits, but they do not actually meet the criteria for an official diagnosis. It is clear that the diagnostic line has to be drawn somewhere, but also important to note that many people who have eating disorders that are bulimic in nature are not getting the help they need because they do not have a diagnosis that can be considered official. This may be doing a disservice to those who need help with behaviors that can be similar to or in the realm of "official" bulimia (Hay & Claudino, 2010). If those who are moving toward bulimia but are not yet meeting the criteria cannot get help, they may only worsen over time.

Causes

In order to work with people who have bulimia and attempt to treat them successfully, it is important to understand what causes the disorder in the first place. That can be somewhat difficult, however, because there are different causes for different people. These are generally in one of two categories: biological and social. The biological factors are largely hormonal and genetic (Russell, 2009). People who have family members with bulimia are much more likely to have it themselves (Palmer, 2004). Additionally, women who have hormonal issues such as polycystic ovary syndrome or severe forms of androgyny can also struggle with bulimia (Palmer, 2004). When estrogen receptors do not work the right way, they can also lead to bulimia, suggesting that there is a correlation between sex hormones and the disorder (Hay & Claudino, 2010).

Studies have also shown that even those who do not have any biological causes or reasons to be bulimic may end up that way because of social issues (Patton, et al., 2008; Russell, 2009). The media portrays an "ideal" body shape that is often severely underweight and typically not realistic for the average person (Russell, 2009). The difficulties with that are seen more commonly among women, but men can still be affected by it. In just a few years of media exposure, studies have shown that the incidence of purging rose dramatically among young women (Russell, 2009). This does not mean that all people who see media portrayals of what people "should" look like will develop bulimia or another eating disorder, but it is very important to consider how bulimia can be affected by what people see on television and in other forms of media. By understanding how significant this is as a reason for bulimic behaviors, more ways to recognize bulimia and more ways to treat it successfully can be located.

Related Disorders

The other mental health disorders that are most commonly related to bulimia are anxiety and depression (Russell, 2009). As many as 70% of bulimics are or have been depressed during their lifetimes (Russell, 2009). Substance use and abuse, as well as substance dependency, are also very common in those who have bulimia (Palmer, 2004; Patton, et al., 2008). Problems with dental health are seen in the majority of people who have bulimia, as well, because of the level of acid that crosses the teeth from frequent vomiting (Palmer, 2004). While these disorders and issues are very commonly seen in individuals who have bulimia, whether they are officially diagnosed or not, it is not necessary for someone who is bulimic to have any other disorders that surround or relate to it. Bulimia may exist all on its own, without any other disorders or conditions being present (Palmer, 2004).