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Bulimia Nervosa

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Bulimia nervosa (Greek: "nervous ox hunger"), "an irresistible urge to overeat, followed by self-induced vomiting or purging", was first described in the medical literature in 1979. However, overeating is mentioned in Greek mythology, and purging has often been associated with overeating. Traditionally bulimic patients purge by vomiting, but the availability of laxatives -- and even diuretics -- give these patients more options. Purging, and the side effects of purging, are responsible for many of the medical problems that bulimic patients develop.

Symptoms and Signs

The hallmarks of bulimia (and the basis of the American Psychiatric Association criteria for its diagnosis) are:

Binge eating
We define this as eating, in any time period, more food than most other people would eat in the same time period and under the same circumstances. A binge meal may contain 10,000 calories, or more, but may also involve no more food than a normal meal. (A football player eats very large meals during training and on game days, but the nutrition in those meals more or less matches the energy he expends).
Loss of control over eating during the binge
The difference between ordinary eating and bingeing is that the bingeing patient feels like she has lost control of her eating (what she is eating, how much she is eating, and not being able to stop herself from eating once she has had enough).
Inappropriate ways of making up for the binges
The classic "purging-type" bulimic patient tries to get rid of the binged food after she eats it. Purging is often done with emetics such as ipecac, but many patients learn to make themselves vomit with their fingers or with objects like toothbrush handles. Some patients use laxatives or enemas to increase stool output, hoping that this will reduce their weight and decrease absorption of calories. Other bulimic patients take diuretics to lose weight; this gets rid of water but doesn't really affect body weight otherwise. Bulimic (and anorexic) diabetics have been known to stop their own insulin: this causes their blood sugar to go way up, which also leads to increased urination (among a lot of other bad effects). Some bulimic and anorexic patients have used stimulants (such as the medications for ADHD) or thyroid hormone to make themselves lose weight.
Less commonly, we see non-purging bulimic patients. These patients also binge but fast between binges or exercise excessively.

In early bulimia, a patient often feels that she now has control over her weight, and has the satisfaction of being able to eat large amounts of food without gaining weight. As the disease progresses, though, her feelings of control and satisfaction wear off. Hunger after purging leads to “compensatory” bingeing, and a vicious cycle develops, made worse by other provocations to binge including anxiety, depressed mood, and boredom. Substances that make her feel less inhibited, such as alcohol, also make things worse, and certain “forbidden” foods can also trigger binges. Patients tend to binge while they are alone, and they may hoard food so they can binge in privacy later. Like anorexic patients, bulimic patients will go to great lengths to hide their disordered eating from family and friends.

Bulimia usually starts in early adulthood or the late teens, unlike anorexia which tends to start around puberty. Bulimia often starts during or after a period of dieting, when a patient figures out that she can cut the calories her body keeps in by purging after eating. However, many patients begin bingeing before changing their diets. Like patients with anorexia, patients with bulimia are much more worried about their appearance and weight than they should be. In fact, almost one-third of bulimic patients were previously anorexic. Also like anorexia, bulimia sometimes runs in families. However, unlike most anorexic patients, bulimic patients often were obese as children or had obese parents, and are more likely to have been criticised for being overweight or for their eating habits than are anorexic patients. Anxiety and mood problems are also common in bulimic patients than in other groups; as one example, up to 3/4 of bulimic patients also have or have had an affective disorder such as depression. Substance abuse is also seen more often in bulimic patients than in other groups. Past abuse, especially sexual abuse, in childhood is associated with later development of eating disorders, particularly bulimia; and bulimic patients also seem more likely than others to be novelty-seeking and impulsive.

Most bulimic patients are either overweight or of normal weight. This can actually be dangerous: anorexic patients usually look like they are starving but bulimics may appear relatively normal even though they are really quite ill. The most dangerous problem in bulimia is imbalance of important minerals, especially potassium. The electrical cells in your body (your nerve cells and your muscles) depend on tightly-controlled levels of potassium in your blood. Both vomiting and most diuretics make your body get rid of potassium, and some laxatives can mess up your mineral balance as well. If your blood potassium level is either too high or too low, those cells do not work properly, and the consequences can range from seizures to a stopped heart. (This has happened in some very (in)famous cases.) Purging can also upset acid-base balance in the body, making body fluids either too acid or not acid enough, and can also affect the heart's electrical systems in other ways,

Other major potential problems can result from retching and vomiting. These range from bleeding from, to rupture of, the stomach or esophagus due to tissue being torn while retching and vomiting. A patient can also bleed from the back of the mouth and throat after lacerations from whatever she sticks down there to make herself vomit. As with any vomiting, it is possible for someone to aspirate the vomited material into the windpipe and lungs; this can kill you, too.

Another serious problem is seen in bulimics who use ipecac to make themselves vomit. When taken repeatedly for a long time, ipecac can cause myopathy (muscle malfunction) in both skeletal muscles (like those in the arms and legs) and in the heart muscle. This usually doesn't happen until someone takes a lot of ipecac over weeks to months, but some bulimic patients do just that: I have taken care of patients with impending heart failure who got there because they had been abusing ipecac for months. Patients with ipecac myopathy usually get better once they stop using ipecac, but this requires time and psychotherapy.

Other, and usually less serious, problems seen in bulimic patients include damage to the teeth (caused by stomach acid in patients who vomit to purge). Patients who make themselves vomit with their fingers may have small lacerations and scars from old lacerations on their knuckles, caused by scraping the knuckles with their teeth while making themselves vomit; this is known as the Russell sign, after the adolescent medicine specialist who first described bulimia.

Treatment of Bulimia Nervosa

See our separate page on treatment of eating disorders.

The Long-Term Outlook

Like anorexia, bulimia is often chronic. There are not yet good published studies on how bulimic patients do in the long run; in those studies that have been published, "good outcomes" (which are not defined the same way in different studies) were seen in anywhere from 24% to 74% of bulimic patients. However, since there are therapies and medications that have been shown to be effective in bulimic patients, this is likely to improve. The mortality (death rate) is reportedly a bit lower for bulimic patients than for anorexic patients, but I personally worry much more about my bulimic patients since none of us can tell by looking at them whether they are in deep metabolic trouble.

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Copyright © 2007, 2010 Vinay N. Reddy, M.D. All rights reserved.
Written 02/28/2007; first posted 08/09/07; last revised 12/14/10 counter