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Bulimia nervosa in Wikipedia

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This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Bulimia nervosa". (Source - Retrieved 2006-09-07 14:21:14 from


Bulimia nervosa, more commonly known as bulimia, is an eating disorder. It is a psychological condition in which the subject engages in recurrent binge eating followed by an intentional purging. This purging is done in order to compensate for the excessive intake of the food and to prevent weight gain. Purging typically takes the form of:

DSM-IV criteria

The following six criteria should be met for a patient to be diagnosed with bulimia$[1]$ $[2]$:

  1. The patient feels incapable of controlling the urge to binge, even during the binge itself, and consumes a larger amount of food than a person would normally consume at one sitting.
  2. The patient purges him or herself of the recent intake, resorting to vomiting, laxatives, diuretics, exercising, etc.
  3. The patient engages in such behavior at least twice per week for four months.
  4. The patient is focused upon body image and desperate desire to appear thin.
  5. The patient does not meet the diagnostic criteria for anorexia nervosa. (Some anorexics may demonstrate bulimic behaviours in their illness: binge-eating and purging themselves of food on a regular or infrequent basis at certain times during the course of their disease. Alternatively, some individuals might switch from having anorexia to having bulimia. The mortality rate for anorexics who practice bulimic behaviors is twice that of anorexics who do not. $[3]$)
  6. The patient is of normal weight or overweight.

Please note that, in general, diagnostic criteria are considered a guide. A legitimate clinical diagnosis can be made when the majority of the criteria are met.

History of bulimia nervosa

Bulimia nervosa was first described by Professor Gerald Russell in 1979 whilst he worked at the Royal Free Hospital, London. Bulimia nervosa has been recognized as an autonomous eating disorder by the American Psychiatric Association since 1980 $[4]$. The word “bulimia” is Latin, getting its roots from the Greek word “boulimia” which directly translates to mean “extreme hunger” $[5]$.


Bulimia is often less about food, and more to do with deep psychological issues and profound feelings of lack of control. Binge/purge episodes can be severe, sometimes involving rapid and out of control feeding that can stop when the sufferers "are interrupted by another person or when their stomach hurts from over-extension. This cycle may be repeated several times a week or, in serious cases, several times a day."$[6]$ Sufferers can often "use the destructive eating pattern to gain control over their lives"$[7]$.

Genetic factors

Research done in 2003, shows a link to the development of bulimia nervosa with an area on the 10p chromosome. This evidence further supports the belief that the susceptibility of developing an eating disorder (specifically bulimia) is strongly linked to genetic components $[8]$. Familial links include a history of obesity, substance abuse, and depressive disorder. Twin studies also strongly support this genetic factor. While both genetics and unique environments contributed to the development of the disorder, twin studies indicate a slightly stronger effect from the genetic predisposition than from environmental circumstances. Significant rates of sexual assault and violence also indicate a possible correlation between victimization and the development of bulimia. Chemically, low levels of serotonin contribute to the continuation of the bulimic cycle; whether it is contributing to or arising from the nutritional deficiency and vomiting is still undetermined. The protein leptin decreases hunger levels in a person, and is often blocked in patients with bulimia, causing abnormal levels of hunger . Due to the binging and purging cycle the stomach is frequently stretched to an enlarged state, and over the progression of time, becomes permanently enlarged, making it necessary for more food to be in the person’s stomach to reach a level of satisfaction. This is a primary cause of the need for a bulimic to gradually increase the caloric size of their binges, as the original quantities no longer satisfy their enlarged stomach $[9]$.

Environmental factors

Rates of bulimia are much more prevalent in western civilizations, to the point that the disorder is almost non-existent in eastern cultures. As western civilization is becoming a more prominent figure in other cultures, through movies and television primarily, we are seeing a dramatic increase in the incidence of eating disorders in these cultures. The disorder is also much more prevalent in the Caucasian race, though as media influences have become stronger, the disorder is becoming a rising problem in the African American and Hispanic communities. Women are also 90% of patients who suffer from this disorder. Females involved in activities that put an extreme emphasis on thinness and body type (such as gymnastics, dance and cheerleading) are at the greatest risk for the development of eating disorders. $[10]$.

Patterns of bulimic cycles

The frequency of bulimic cycles will vary from person to person. Some will suffer from an episode every few months while others who are more severely ill may binge and purge several times a day. Some people may vomit automatically after they have eaten any food. Others will eat socially but may be bulimic in private. Some people do not regard their illness as a problem, while others despise and fear the vicious and uncontrollable cycle they are in $[11]$.

Subtypes of bulimia

The specific subtypes differ in the way the bulimic relieves themself of the binge.

Purging type - The purging type uses self-induced vomiting, laxatives, diuretics, enemas, or ipecac, as a mean of rapidly extricating the contents for their body. This type generally is more commonly found, and can use one or more of the above methods on a regular basis $[12]$.

Non-Purging Type - This type of bulimic is very rarely found (only approximately 6%-8%), as it is a less effective means of ridding the body of such a large number of calories. This type of bulimic engages in excessive exercise or fasting following a binge in order to counteract the large amount of calories previously ingested. This is frequently observed in purging type bulimics as well, however this method is not their primary form of weight control following a binge $[13]$.

Consequences of bulimia nervosa

  • Malnutrition
  • Dehydration
  • Electrolyte imbalance
  • Hyponatremia
  • Vitamin and mineral deficiencies
  • Teeth erosion and cavities, gum disease
  • Sialadenosis (salivary gland swelling)
  • Potential for gastric rupture during periods of bingeing
  • Esophageal reflux
  • Irritation, inflammation, and possible rupture of the esophagus
  • Laxative dependence
  • Peptic ulcers and pancreatitis
  • Emetic toxicity due to ipecac abuse
  • Swelling of the face and cheeks, especially apparent in the lower eyelids due to the high pressure of blood in the face during vomiting.
  • Callused or bruised fingers
  • Dry or brittle skin, hair, and nails, or hair loss
  • Lanugo
  • Edema
  • Muscle atrophy
  • Decreased/increased bowel activity
  • Digestive problems that may be triggered, including Celiac, Crohn's Disease
  • Low blood pressure, hypotension
  • Orthostatic hypotension
  • High blood pressure, hypertension
  • Iron deficiency, anemia
  • Hormonal imbalances
  • A case of the television show "Untold Stories of The ER", airing on TLC in Canada, a young girl with a severe case of Bulimia nervosa managed to get her gag reflex suppressed, resulting in her using forks to induce vomiting, which ultimately got stuck very deep in her esophagus, and was almost in her stomach. She is lucky, as she escaped with no damage, but her parents found out and she had to be treated accordingly.
  • Hyperactivity
  • Depression
  • Insomnia
  • Amenorrhea
  • Infertility
  • Polycystic Ovary Syndrome
  • High risk pregnancy, miscarriage, still-born babies
  • Diabetes
  • Elevated blood sugar or hyperglycemia
  • Ketoacidosis
  • Osteoporosis
  • Arthritis
  • Weakness and fatigue
  • Chronic Fatigue Syndrome
  • Cancer of the throat or voice box
  • Liver failure
  • Kidney infection and failure
  • Heart failure, heart arrhythmia, angina
  • Seizure
  • Paralysis
  • Potentially death caused by heart attack or heart failure; lung collapse; internal bleeding, stroke, kidney failure, liver failure; pancreatitis, gastric rupture, perforated ulcer, depression and suicide.


As mentioned earlier, all six of the criteria listed in the DSM are required for a classic diagnosis of bulimia nervosa. However, these symptoms are often difficult to spot, especially since, unlike anorexia nervosa, in order to be classified as bulimic the person must be of normal or higher weight. Likewise, the person is less likely to drop a significant amount of weight on a continual basis as does the anorectic, making the physical symptoms less noticeable, despite the fact that internal bodily functions are suffering. Because this disorder carries a great deal of shame, the bulimic will desperately try to hide their symptoms from family and friends. This disorder is more likely to span over a lifetime unnoticed, causing a great deal of isolation and stress for the suffering individual. Despite the frequent lack of obvious physical symptoms, bulimia nervosa has proven to be fatal, as malnutrition takes a serious toll on every organ in your body. If any of the symptoms above are noticed one should consult with a doctor or psychologist for further assistance $[14]$.

Related psychological disorders

It is not uncommon that a patient with bulimia nervosa will also have some anxiety or mood disorder as well. Most commonly associated with bulimia is the incidence of anxiety, one study noted this in 75% of bulimic patients. Also prominent in bulimic patients are mood disorders, most commonly depression as well as substance abuse issues. However recent research suggest that depression is a consequence of the eating disorder itself, rather than the other way around. $[15]$. They are also more likely to attempt suicide, and engage in impulsive behaviors.

Differences between anorexia nervosa and bulimia nervosa

The main criteria differences involve weight, as an anorexic must technically be classified as underweight (defined as a BMI < 18.5). Typically an anorexic is defined by the refusal to maintain a normal weight by self-starvation. Another criteria which must usually be met is amenorrhea, the loss of her menstrual cycle not caused by the normal cessation of menstruation during menopause. Generally the anorexic does not engage in regular binging and purging sessions. In the rare instant that this is observed, in that the patient binges and purges as well as fails to maintain a minimum weight they are classified as a purging anorexic, due to the underweight criteria being met. $[16]$ Characteristically, those with bulimia nervosa feel more shame and out of control with their behaviors, as the anorexic meticulously controls her intake, a symptom that calms her anxiety around food as she feels she has control of it, naïve to the notion that it, in fact, controls her. For this reason, the bulimic is more likely to admit to having a problem, as they do not feel they are in control of their behavior. The anorexic is more likely to believe they are in control of their eating and much less likely to admit to needing help, or that a problem even exists in the first place. Similarly, both anorexics and bulimics have an overpowering sense of self that is determined by their weight and their perceptions of it. They both place all their achievements and successes as the result of their body, and for this reason are often depressed as they feel they are consistently failing to achieve the perfect body. For the bulimic, because she cannot achieve the low weight she feels physically that she is a failure and this outlook infiltrates into all aspects of her life. The anorexic cannot see that she is truly underweight and is constantly working towards a goal that she will never meet. Because of this misconception she will never be thin enough, and therefore will be always working towards this unattainable goal. She too allows this failure at achieving the “perfect body” to define her self worth. As both the anorexic and bulimic never feel satisfaction in the more important part of their lives, depression often accompanies these disorders.$[17]$

Treatment of bulimia nervosa

Treatment is most effective when it is implemented early on in the development of the disorder. Unfortunately, since this disorder is often easier to hide and less physically noticeable, diagnosis and treatment often come when the disorder has already become a static part of the patient’s life. Historically, those with bulimia were often hospitalized to end the pattern and then released as soon as the symptoms had been relieved. However, this is now infrequently used, as this only addresses the surface of the problem, and soon after discharge the symptoms would often reappear as severe, if not worse, than when they had originally been.

There are several residential treatment centers across the country, which offer long term support, counseling, and symptom interruption. The most popular form of treatment for the disorder involves some form of therapy, often times group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatments and are members of these same treatment groups. This is because anorexia and bulimia often go hand in hand, and it is not unlikely that one has at some point participated in both. Some refer to this as "symptom swapping". These forms of therapy address both the underlying issues which cause the patient to engage in these behaviors, as well as the actual food symptoms as well. In combination with therapy, many psychiatrists will prescribe anti-depressants or anti-psychotics. Anti-depressants come in different forms, and the most promising drug to respond to bulimia has been Prozac. In a study done with 382 bulimia patients those who took between 20-60 mg of the drug reduced their symptoms from 45% to 67%, respectively. However, Prozac is the only drug that has been tested for bulimia, so it is quite possible that several others could be more effective. Often insurance companies will not pay for other drugs for the patient until he or she has tried Prozac, because it has some positive outcome results.

Anti-psychotics are also used, but in smaller doses than are used for treating schizophrenia. With an eating disorder, the patient perceives reality differently and has difficulty grasping what it is like to eat normally. Unfortunately, since this disorder has only recently been recognized by the DSM, long-term outcomes of people with the disorder are unknown. Current research indicates that up to 30% of patients rapidly relapse, while 40% are chronically symptomatic.

The rate in which the patient receives treatment is the most important factor affecting prognosis. Those who receive treatment early on for the disorder have the highest and most permanent recovery rates.

Mortality risk

Eating disorders have one of the highest death rates of all mental illnesses. The Eating Disorders Association (UK) estimates a 10% mortality rate. An 18% mortality rate has been suggested for Anorexia Nervosa.[1] In addition to the risk of suicide, “death can occur after severe bingeing in bulimia nervosa as well”.$[18]$ For perspective, these death rates are higher than those of some forms of cancer.

At-risk groups

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Risk factors for bulimia are similar to those of other eating disorders, such as anorexia nervosa:

  • those of age 10 through to 25
  • athletes
  • people who are active in dancing, modeling or gymnastics
  • students who are under heavy workloads
  • those who have suffered traumatic events in their lifetime such as child abuse and sexual abuse
  • those positioned in the higher echelons of the socioeconomic scale (celebrities)
  • the highly intelligent and/or high-achievers.
  • perfectionists

The majority of bulimic patients are young females from 10 to 25 years old, although the disorder can occur in people of all ages and both sexes.

There can be a popular assumption that eating disorders are ‘female diseases’, but the illnesses do not discriminate based on gender, and males can also suffer from them: “even if only 5% of sufferers are male, hundreds of thousands of young men are affected…Studies have been conducted within the homosexual subculture, and have also focused on males who suffer from anorexia and bulimia. These point to a direct connection between gender identity conflict and eating disorder in males but not in females. This does not indicate that only gender-conflicted males suffer from eating disorders, but there is a tendency for eating disorders in males to go unrecognised or undiagnosed, due to reluctance among males to seek treatment for these stereotypically female conditions."


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