Evelyn Attia, MD, Professor of Psychiatry;Professor of Clinical Psychiatry, Columbia University Medical Center, New York State Psychiatric Institute;Weill Cornell Medical College, New York Presbyterian Hospital;B. Timothy Walsh, MD, Ruane Professor of Psychiatry;Founding Director, Eating Disorders Research Unit, College of Physicians and Surgeons, Columbia University;New York State Psychiatric Institute
Bulimia nervosa is characterized by the repeated rapid consumption of large amounts of food (binge eating), followed by attempts to compensate for the excess food consumed (for example, by purging, fasting, or exercising).
People eat large amounts of food, then induce vomiting, use laxatives, diet, fast, or vigorously exercise to compensate.
Doctors suspect the diagnosis when people are overly concerned about their weight and their weight fluctuates a lot.
Cognitive-behavioral therapy, a selective serotonin reuptake inhibitor (a type of antidepressant), or both may be used to treat the disorder.
As in anorexia nervosa, bulimia nervosa is influenced by hereditary and social factors. Also as in anorexia nervosa, most people who have bulimia nervosa are young women, are deeply concerned about body shape and weight, and belong to the middle or upper socioeconomic classes. Bulimia nervosa affects mainly adolescents and young adults. In a given year, about 1 in 100 young females have bulimia nervosa. The disorder is much less common among males.
People with bulimia nervosa have repeated episodes of binge eating. That is, they eat much larger amounts of food than most people would eat in a similar time under similar circumstances. The amount considered excessive for a normal meal may differ from that for a holiday meal.
Emotional stress often triggers the binges, which are usually done in secret. Binge eating, which is accompanied by a feeling of a loss of control, usually includes eating when not hungry and eating to the point of pain.
People tend to consume sweet, high-fat foods, such as ice cream and cake. The amount of food consumed varies and sometimes involves thousands of calories. Binges may occur as often as several times a day.
Did You Know?
People with bulimia nervosa tend to feel very remorseful or guilty about their behavior.
People with bulimia nervosa may have scars on their knuckles from using their fingers to induce vomiting.
In an attempt to counteract the effects of the excess food, people use various means to purge:
Rigorously dieting or fasting
Any combination of the above
Many also take diuretics to treat perceived bloating.
Unlike in anorexia nervosa, the body weight of people with bulimia nervosa tends to fluctuate around normal. Only a few are overweight or obese.
Self-induced vomiting can erode tooth enamel, enlarge the salivary glands in the cheeks (parotid glands), and inflame the esophagus. Vomiting and purging can lower potassium levels in the blood, causing abnormal heart rhythms. Sudden death can result from an abnormal heart rhythm in people who repeatedly take large quantities of ipecac to induce vomiting. Rarely, during a binge or purge, the stomach ruptures or the esophagus tears, leading to life-threatening complications.
People may be preoccupied with and judge themselves based on their weight and body shape. Their self-esteem is largely based on their body weight and shape.
Compared with people who have anorexia nervosa, those who have bulimia nervosa tend to be more aware of their behavior and to feel remorseful or guilty about it. They are more likely to admit their concerns to a doctor or other confidant. Generally, people with bulimia nervosa are more outgoing. They also are more prone to impulsive behavior, drug or alcohol abuse, and depression. They are anxious about their weight and about participation in social activities.
A doctor's evaluation
Bulimia nervosa is suspected when people, particularly young women, express marked concern about weight gain and have wide fluctuations in weight, especially if there is evidence of excessive laxative use (such as diarrhea and abdominal cramps).
Doctors also check for other clues:
Swollen salivary glands in the cheeks
Scars on the knuckles from using the fingers to induce vomiting
Erosion of tooth enamel from stomach acid
A low level of potassium detected by a blood test
Doctors diagnose bulimia nervosa when people report binge eating followed by purging once a week for at least 3 months and base their self-image largely on their weight and shape.
Treatment may include cognitive-behavioral therapy, interpersonal psychotherapy, and drug therapy.
Cognitive-behavioral therapy is usually used. Goals are
To motivate people to change
To establish a regular and flexible pattern of eating
To reduce their preoccupation with body weight and shape
People meet with a therapist—individually or in a group—once or twice a week over a period of 4 to 5 months, for a total of about 16 to 20 sessions. Cognitive-behavioral therapy eliminates binge eating and purging in about 30 to 50% of people with bulimia. Many others also improve, but others drop out of therapy or do not respond. Those who improve usually continue to do well.
Interpersonal psychotherapy is an alternative when cognitive-behavioral therapy is unavailable. It helps people identify and change interpersonal problems that may be contributing to the eating disorder. This therapy does not involve telling people how to change, does not interpret their behavior, and does not deal directly with eating disorder.
Selective serotonin reuptake inhibitors, a type of antidepressant, can reduce the frequency of binge eating and vomiting, but how effective these drugs are in the long term is not clear. These drugs also effectively treat anxiety and depression, which are common among people with bulimia nervosa.