Bulimia nervosa

Overview
Bulimia nervosa is a type of eating disorder in which frequent binge-eating episodes and inappropriate methods are used to prevent weight gain. Binge-eating episodes include eating large amounts of food (about 1,000 calories) in a relatively short period of time (less than two hours). There are two types of bulimia: purging and nonpurging. With the purging type, the person regularly engages in self-induced vomiting or excessive use of laxatives, diuretics or enemas (solutions used to stimulate bowel movements). With nonpurging bulimia, weight gain is prevented with other inappropriate compensatory behaviors, such as fasting or excessive exercise. Less is known about the nonpurging form of bulimia because it is less common than the purging type.
Although certain characteristics of bulimia may overlap with those of anorexia, another type of eating disorder, one main difference is that people who have bulimia are able to maintain body weight at or above a minimally normal level.


Causes/associated factors
Bulimia affects about 1 to 4 percent of American women. It affects women about ten times more often than men. Like all eating disorders, bulimia occurs in all social classes and ethnic groups. Because eating disorders are more commonly associated with Caucasian females, they may be underdiagnosed in other ethnic groups. Bulimia is most prevalent in industrialized Western countries, especially among the middle and upper socioeconomic classes.
The condition, which tends to run in families, most commonly begins in women between ages 15 and 18, and for males between 18 and 26.

Most researchers agree that a person's biological predisposition and a combination of societal, psychological and family pressures contribute to the development of bulimia. Other risk factors include low self-esteem, stress, and alcohol or drug abuse. Parents of people who have bulimia often have high expectations but offer limited personal contact and affection. People who have bulimia are more likely to be overweight, have overweight parents and, for women, have started menstruating earlier than their peers. For both men and women, the risk is compounded through participation in activities or occupations that emphasize weight, such as gymnastics, figure skating, dancing, modeling, wrestling and body building.

People who have bulimia have an intense fear of fatness and are often disgusted by their own bodies. Typically, a cycle of thoughts, feelings and behavior begins with self-criticism and a focus on weight or body shape. Then, anger, anxiety or depression may trigger a binge. During a binge, a person consumes large amounts of food in a relatively short period of time. Later, guilt and depression may lead to some type of compensation for the binge. Resulting shame and more self-criticism cause the cycle to continue.


Characteristics
Physical characteristics
Physically, bulimia may cause muscle weakness or twitches (from loss of potassium through vomiting or the use of laxatives or diuretics), cramps and abdominal pain. Dizziness and generalized weakness are common. Electrolyte imbalances (characterized by low levels of potassium or sodium), dehydration, swollen salivary glands and pasty, yellowish skin can occur. The person may also develop facial swelling, as well as broken blood capillaries in the face. Women may develop reproductive problems or menstrual irregularities. Self-induced vomiting may lead to calluses on the back of the hands and dental problems, such as eroded tooth enamel, cavities, teeth discoloration, lip sores, gum abscesses and loss of taste. Anemia (a condition marked by a decreased number of red blood cells or hemoglobin, a protein in red blood cells that contains iron) may also develop.

Psychological characteristics
Psychologically, people who have bulimia often become perfectionists with unrealistic expectations. They may be compulsive and tie their sense of self-worth to weight, body shape or thinness. They may have a preoccupation with food and weight control. Sometimes, food becomes a way to cope with other problems. Shame and depression are also common.

Behavioral characteristics
People who have bulimia often stock cupboards with high-calorie foods or hide stashes of food. They may disappear after meals or secretively spend time alone. (Binges can often be immediately stopped by the unexpected appearance of others on the scene.) After a binge, they will often purge, fast, diet or exercise excessively. They may ritually weigh or measure their waist, thighs or other body parts. Some people who have bulimia engage in impulsive behaviors and substance abuse.


Diagnosis
It can be difficult to know whether someone has bulimia. The person's weight is often normal, and the binge eating and purging is typically done secretively. In addition, people who have bulimia often deny they have a problem. If you suspect you or someone you care about has an eating disorder, first consult a medical doctor to evaluate any possible physical or organic causes for the symptoms. Diagnosis is based on careful examination of the person's medical history and a physical exam. A variety of blood tests can help identify a habit of purging.

Treatment
Because eating disorders are so complex, they're best treated through a team approach. Many clinics have eating disorders programs. The earlier the treatment for bulimia begins, however, the better the chances for recovery.
Generally, treatment involves:

medical intervention to resolve the physical complications of bulimia
nutritional counseling to help restore normal nutritional health
individual and/or family counseling to learn about the disease and how to adopt or encourage more healthful habits, promote the long-term change of attitudes, perceptions and behaviors, and recognize the internal critical voice in favor of a more nurturing thought pattern
support groups, for both the patient and his or her family members
dental care
medication therapy, often antidepressants
Exploring new ways to meet personal needs and improve coping skills is often beneficial. For example, assertiveness training and learning how to communicate effectively could be helpful. Based on the high mortality rate associated with bulimia, ongoing medical supervision is crucial. If severe or life-threatening physical complications exist, hospitalization for intensive treatment may be necessary.

Self-care strategies
If you're coping with an eating disorder, there are things you can do in your recovery process. Keep all appointments with your doctor or therapist. Set realistic goals for your weight and personal achievements. Build self-esteem, keep stress under control, and avoid self-judgment. Maintain a positive attitude, and learn to accept yourself and your body as you are. Communicate your feelings and work out conflicts. Remember that support from a professional as well as family and friends is essential.

Because binge eating and purging are solitary activities, avoid being alone during the initial phases of treatment. Do not hoard high-calorie foods, and limit pocket money to prevent buying junk food on impulse. It's also important to eat a healthful diet with regularly scheduled meals, and avoid alcohol and cigarettes. Get plenty of rest, maintain your recommended ideal weight, exercise in moderation, and take any medication as prescribed.

Tips for friends and family members
If you have a friend or family member who has bulimia, keep the following considerations in mind.

Do not focus on controlling the person's eating or weight. Remember that the person's behavior is an attempted solution to a problem, and, most often, one of the problems the person is attempting to solve is a perceived lack of control over his or her life. The person may resist your efforts to control what he or she considers the one thing in life that he or she actually has full control over.

Recognize your limitations. Assuming the person is an adult and he or she is not presenting an immediate danger to himself, herself or others, no one can force him or her to get help. However, you can express your concern in a loving way, find community resources and treatment programs, and encourage the person to seek help.

Recognize the normal feelings often experienced by friends or family members of people who have eating disorders. These include fear about the person's well-being or safety and anger that may be directed at the person who has the eating disorder, yourself for not being able to fix the problem, or doctors or other health care providers for not spotting the problem earlier or doing enough to help. Also understand the mistrust that may result from the person's attempts to deceive others and cover up his or her habit out of shame.

Confront the person assertively. Express your concerns about the person's behavior without violating his or her rights or boundaries. Use "I" statements to express your concern. For example, say, "I'm concerned because you seem preoccupied with your weight," instead of, "You're obsessed with your weight." Avoid generalizing the situation too much or placing blame. Be sensitive to the fact that the person may be ashamed or embarrassed about being confronted about his or her "secret." Do not add to the person's potential guilt or remorse with shaming lectures or exhortations.

Be prepared for denial. People who have eating disorders often experience a great deal of shame in connection with their behavior. Denial of the problem is a part of the illness. To prepare for the denial, have in mind specific examples of the behavior you consider problematic. On the flip side, be suspicious of instant insight with reassurances that he or she will stop. Often, the promise is made only so you will back off.

Offer unconditional support and love. Do not make your love and acceptance conditional on the person's weight, appearance or behavior. Many people who have recovered from eating disorders acknowledge the unconditional love and support of family and friends as a crucial factor in helping them recover.

Learn about eating disorders and seek support from others. You may want to join a support group or look to local organizations or other community resources.

Relapses
Recovery from an eating disorder is often uneven, and relapses are common. If you or a loved one experiences a relapse, contact your health care provider immediately.


Complications
Medical complications of bulimia are primarily due to the effects of purging. Due to low calcium intake, a person who has bulimia may have an increased risk of osteoporosis (the loss of bone mass that leads to brittle bones). Other complications may include:
cardiomyopathy (any disease affecting the structure and function of the heart) related to long-term abuse of syrup of ipecac (The active ingredient of syrup of ipecac, emetine, may lead to heart muscle injury.)
electrolyte abnormality, particularly hypokalemia (low potassium in the bloodstream), which can become chronic and lead to changes in the electrical activity of the heart
dehydration
menstrual dysfunction
swelling of salivary glands (chipmunk-like appearance)
gastrointestinal complications such as gastric dilation, rupture, peptic ulcers, chronic heartburn
abdominal bloating
chronic constipation
dental problems, such as erosion of tooth enamel, cavities, teeth discoloration, ulcers on lips, gum abscesses and loss of taste
In serious cases, the medical complications of bulimia may be fatal. For example, the junction of the esophagus and stomach may become torn, and the rupture of esophageal veins during vomiting can lead to uncontrollable bleeding into the neck or around the heart.


Prevention
Many of the self-care strategies outlined above can also be used to help prevent bulimia. Remember, reasonable eating and exercise habits, a positive outlook and solid self-esteem can create a healthy lifestyle that lasts a lifetime.