Bulimia nervosa in general psychology

Bulimia Nervosa: Diagnosis, Treatments, And Prevention

Bulimia is a serious, multifaceted psychiatric illness that entails physiological, psychological, cultural, and developmental components (McGilley & Pryor, 1998). Over two million adolescent girls and young women in the United States alone are affected by this disorder (Lamb, 1999). The disorder involves the consumption of extremely large amounts of food, also known as binge behavior, and then subsequent efforts to eliminate the food and calories just consumed through the act of purging (vomiting, laxative use, etc.) or non-purging behavior (fasting, excessive exercise). Extreme anxiety, physical discomfort, and intense guilt following a binge provoke the individual with bulimia to engage in purging behavior (McGilley & Pryor, 1998). What differentiates bulimia from anorexia, another prevalent eating disorder, is the presence of the binge eating behavior. Factors that may predispose individuals to bulimia include genetics, as well as personality and psychological factors, such as "perfectionism, impaired self-concept, affective instability, poor impulse control, and an absence of adaptive functioning to maturational tasks and developmental stressors (McGilley & Pryor 1998; 2743)."

Abnormalities in neurotransmitters in the central nervous system have also been found to be a factor in the development of this disorder. The disorder is continually perpetuated by the abnormal psychological states that usually accompany it. In other words, "the physiologic effects of disordered eating appear to maintain the core features of the disorder, resulting in a self-perpetuating cycle (McGilley & Pryor, 1998; 2743)." Environmental factors, such as the presence of mothers that are overly concerned with physical attractiveness or fathers who criticize their weight may also be involved in the experience of bulimia (Lamb, 1999).

Research has determined that the experience of sexual abuse may be related to bulimia (Preti et al., 2006). Preti et al. (2006) investigated the controversial association between bulimia and sexual abuse with the role of bodily dissatisfaction as an intervening variable. The results indicated that individuals who reported childhood sexual abuse scored higher on bulimia diagnostic tests than individuals that did not report childhood sexual abuse. Moreover, the findings of this study suggested that individuals that experienced sexual abuse prior to puberty may be considered to be at risk for the development of bulimia. This relationship may be mediated by the revulsion toward the body that is precipitated by the sexual abuse mixed with general dysmorphic concerns regarding the shape, size, and weight of the body (Preti et al., 2006).

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), the criteria for the diagnosis of bulimia are divided into two subtypes. These two subtypes include patients who binge and then exhibit purging behavior, and patients who binge and then exhibit non-purging behavior. The first two characteristics of bulimia are bingeing and compensatory behavior. What constitutes binge behavior? Binge behavior is defined as eating copious amount of food, more than most people would, within a discrete time-frame and in a manner that demonstrates a lack of control. Compensatory behavior, the other main characteristic of bulimia, is a recurrent behavior that is executed in order to avoid weight gain. This compensatory behavior can be either purging (vomiting, laxative use, etc.) or non-purging (fasting, excessive exercise, etc.) in nature. Bulimia is characterized by the occurrence of these binge and purge behaviors at a rate of at least twice per week for a period of three months. Along with the presence of bingeing and compensatory behavior, another criterion for diagnosis of bulimia is dysmorphic self-evaluation that is heavily influenced by weight and body shape (American Psychological Association, 1994).

During the past 30 years, bulimia has become more prevalent, and the experience of the disorder is 10 times more common among females than among males (McGilley & Pryor, 1998). In total, it has been determined that bulimia affects 1 to 3% of adolescent females and young women, and the peak age of onset is between the ages of thirteen and twenty years (McGilley & Pryor, 1998).

Although the occurrence of bulimia among males is rare in comparison to females, research has indicated that there is an increasing prevalence of adolescent males presenting with bulimia (Ray, 2004). It is important for adults, such as school counselors, to be aware of this phenomenon so that the deleterious effects of the disorder on both mental and physical health can be alleviated or prevented. School counselors, in particular, have direct contact with young students who may be at-risk for bulimia. These professionals can use this position to provide identification, referral, psychoeducation, and support services that focus on bulimia to students, parents, teachers and the community (Ray, 2004).

Bulimia is often comorbid with other psychiatric conditions (McGilley & Pryor, 1998). The psychiatric conditions that commonly are associated with bulimia are: mood disorders (depression, bipolar disorder); substance-related disorders (alcohol and drug abuse); anxiety disorders (obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, post-traumatic stress disorder); and personality disorders (borderline personality disorders, histrionic personality disorder, narcissistic personality disorder, antisocial personality disorder) (McGilley & Pryor, 1998). Between two percent and fifty percent of women that have bulimia also exhibit a personality disorder (McGilley & Pryor, 1998). If a comorbid substance-related disorder is present, it must be addressed prior to treatment for bulimia in order to ensure effective results (McGilley & Pryor, 1998).

Comorbidity of all types complicates treatment, so it is therefore necessary that treatments for bulimia take the possibility of other psychiatric conditions into account (McGilley & Pryor, 1998).

Research has established a significant relationship between bulimia and obsessive-compulsive disorder (OCD) (Roberts, 2006). Of the compulsions associated with OCD, ordering and arranging behaviors have been found to be most predictive of bulimia and eating disorders in general (Roberts, 2006). This finding points to implications for the prevention, diagnosis and treatment of bulimia. Researchers and Clinicians may find it beneficial to take the high rate of bulimia comorbid with OCD into consideration in the planning of prevention and treatment initiatives for bulimia. These interventions could include a focus on the prevalence of ordering and arranging compulsions among this comorbid population. Furthermore, it is necessary for healthcare professionals to be aware of the link between these two disorders in order to develop a further understanding of factors that influence the exacerbation and alleviation of bulimic symptoms (Roberts, 2006). For example, clinicians could call for routine screening measures for OCD symptoms when a patient presents with a bulimia diagnosis. If OCD is found, treatment would then need to be customized in order to account for the presence and interactions of both disorders (Roberts, 2006).

Bulimia can result in several medical complications. Some of these are transient, non-serious symptoms, while others indicate chronic, possibly life-threatening conditions (McGilley & Pryor, 1998). Bingeing may result in gastric rupture, nausea, abdominal pain, weight gain, and prolonged digestion. Purging, which most often takes the form of vomiting, may result in dental erosion, enlarged salivary glands, oral and hand trauma, damage to the esophagus and pharynx, heartburn, sore throat, electrolyte imbalances, hypokalemia, and cardiac arrhythmias, among other possible problems (McGilley & Pryor, 1998).

Treatments for bulimia include both psychological and pharmacological interventions. Some drug treatments include antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (McGilley & Pryor, 1998). It has been determined that patients who receive fluoxetine, a selective serotonin reuptake inhibitor, on a daily basis show the best treatment response, with a 67% reduction in bingeing and a 56% reduction in purging (McGilley & Pryor, 1998).

Psychotherapy is also used successfully in the treatment of bulimia. Cognitive-behavioral therapy (CBT), in particular has demonstrated effective results when used alone or in combination with other methods of treatment (McGilley & Pryor, 1998). CBT involves a systematic series of interventions that focus on the cognitive aspects involved in bulimia. The aspects include "preoccupation with body, weight and food, perfectionism, dichotomous thinking and low self-esteem (McGilley & Pryor, 1998; 2747)." Behavioral components to the disorder are also addressed, including bingeing, purging, disturbed eating patterns, diets, and abnormal exercising practices (McGilley & Pryor, 1998). The goals of CBT include control over the behaviors associated with the disorder, and the adjustment of thought processes in order to improve self-esteem, assertiveness, and the expression of feelings (McGilley & Pryor, 1998).