Bulimia is defined as an eating disorder characterized by recurrent episodes of binge eating followed by self-induced vomiting, laxative or diuretic abuse, vigorous exercise, or fasting.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), the reference that doctors use to diagnose mental illness, specifies that a person must have an eating binge and try to compensate for it on average twice a week for three months to meet the diagnostic criteria for bulimia. A binge is an episode in which someone consumes a larger amount of food within a limited period of time than most people would eat in similar circumstances. Most bulimics report feelings of loss of control associated with bingeing. A second criterion of bulimia is excessive concern with one's body shape and weight.
There are two subtypes of bulimia, purging and nonpurging, according to the methods used by the patient to prevent gaining weight
after a binge. People who have the purging subtype use vomiting, laxatives, enemas, or diuretics to keep from gaining weight; in the nonpurging subtype, the person fasts or overexercises to prevent weight gain. The important point is that bulimics do something after a binge to compensate for their eating. There is another type of eating disorder called binge eating disorder, in which the person has eating binges but does not try to vomit, exercise, or do anything else to prevent gaining weight.
Princess Diana and Bulimia
Princess Diana (1961–1997) is sometimes credited with bringing bulimia out into the open by talking to the press about her own struggles with the disorder. The princess gave an interview in 1995 in which she described her bulimia: “I had bulimia for a number of years. And that's like a secret disease. You inflict it upon yourself because your self-esteem is at a low ebb, and you don't think you're worthy or valuable. You fill your stomach up four or five times a day—some do it more—and it gives you a feeling of comfort. It's like having a pair of arms around you, but it's temporary, temporary. Then you're disgusted at the bloatedness of your stomach, and then you bring it all up again…. It was a symptom of what was going on in my marriage.”
When asked by the interviewer whether she had asked for help from anyone else in the royal family, Diana said, “You have to know that when you have bulimia you're very ashamed of yourself and you hate yourself—and people think you're wasting food—so you don't discuss it with people. And the thing about bulimia is your
weight always stays the same, whereas with anorexia you visibly shrink. So you can pretend the whole way through. There's no proof.”
There is some disagreement about the demographics of bulimia, partly because the rules for diagnosing it have changed over time. The usual figure given for bulimia in the United States is 1–3 percent of high school- and college-age women. Many doctors think, however, that
bulimia is underdiagnosed because most people with the disorder are of average weight or only slightly overweight. In addition, there are large numbers of teenagers and young adults who have disordered eating patterns but do not meet the full criteria for bulimia; there may be twice as many young people in this second group as those who meet the full DSM-IV definition.
The gender ratio is usually given as ten females to every one male affected, but some people think that as many as 15 percent of bulimics are male. Gay men appear to be at greater risk of developing bulimia than heterosexual men.
At one time bulimia was thought to affect mostly Caucasian women, but the rates among African American and Hispanic women have risen faster than the rate of bulimia for the female population as a whole, at least in the United States. Occupation appears to be a major risk factor for bulimia. Women whose careers depend on appearance or a certain body build, such as ballet dancers, models, and professional athletes, are reported to be four times as likely to develop bulimia as women in the general population.
The causes of bulimia are not known for certain, but are thought to be a combination of genetic factors (possibly unusual sensitivity to foods high in carbohydrates); the emotional climate in the patient's family; and pressures in the wider society to live up to a standardized image of beauty. In terms of family patterns, people with bulimia often describe their families as conflicted and their parents as either distant and uncaring or hostile and critical.
Bulimia is associated with a number of physical symptoms. Binge eating by itself rarely causes serious medical complications, but it is associated with nausea, abdominal bloating and cramping, slowed digestion, and weight gain.
Bulimics who force themselves to vomit after a binge may develop serious medical problems, including:
- Erosion of the enamel on the teeth, caused by stomach acid in the vomited material.
- Enlargement of the salivary glands.
- Scars and calloused areas on the knuckles from contact with the teeth.
- Irritation of the throat and esophagus.
- Low blood pressure and slowed heart rate.
- Electrolyte imbalances. The loss of fluids from repeated vomiting can deplete the body's stores of hydrogen chloride, potassium, sodium, and magnesium. The loss of these chemicals in turn can sometimes affect heart rhythm.
Bulimia is usually diagnosed during an office visit to the patient's primary care doctor, although she or he may be sent to a psychiatrist for an additional evaluation. Primary care doctors are now encouraged to give a screening test to an adolescent or young adult who seems unusually concerned about their weight or asks the doctor a lot of questions about weight loss. These screeners are short sets of five questions about eating habits that the patient can quickly answer. If the doctor thinks that the patient may have bulimia, he or she can look for some of the physical signs that accompany the disorder, such as whether the teeth and salivary glands are normal. In most cases the doctor will order laboratory tests of the patient's blood and urine to make sure that her blood chemistry is normal. Most doctors will also give the patient an electrocardiogram (ECG) to check the patient's heart rhythm. This test is important because some types of chemical imbalances in the blood (from vomiting or using diuretics) can lead to irregular heart rhythms.
Another important part of evaluating a patient for bulimia is a mental status examination. The doctor will need to check the patient for signs of anxiety disorders or depression, because a high proportion of bulimics have a mood disorder. In addition, people with bulimia are more likely to be treated successfully for their eating disorder when their anxiety or depression is also being treated.
Treatment for bulimia consists of psychotherapy combined with medications. The type of psychotherapy most often recommended for bulimics is cognitive-behavioral therapy (CBT), along with interpersonal therapy. In CBT, the patient is helped to recognize the distortions in their mental image of their body and to correct irrational beliefs about food and eating. Family therapy may be recommended if the patient's family appears to be a major cause of his or her emotional distress; as of late 2007, there was some evidence that family therapy is more helpful for some patients with bulimia than individual therapy. Some bulimics also benefit from group therapy or support group meetings.
The medications most often prescribed for bulimics are antidepressants, in particular such drugs as fluoxetine (Prozac) and sertraline (Zoloft). Scientists do not fully understand how these drugs help in treating bulimia, but some think that they help to regulate chemical imbalances in the patient's central nervous system.
The prognosis of bulimia depends on several factors, including the patient's age at diagnosis, the quality of family life, and the number of close friendships that she or he has. Patients who are diagnosed early, have good relationships with their parents, and have several close friends are more likely to recover. About half of bulimics have good outcomes after treatment, 18 percent have intermediate outcomes, and 20 percent have poor outcomes.
While it is difficult to change an entire society and its overly high valuation of physical attractiveness, parents can certainly lower a child's risk of bulimia in later life by creating a warm and loving home. It is important to convey to children that they are loved as whole persons with minds and spirits, not just outwardly pleasing faces and bodies.
It is not known with certainty whether bulimia is increasing in the United States, partly because it overlaps with other eating disorders in some people and partly because doctors are looking more closely at men who may be bulimic but were not diagnosed with the disorder in the past. Although doctors are looking for better treatments of bulimia, including new medications, further research in the chemistry of the brain is needed.
SEE ALSO Anorexia; Depression; Obesity
WORDS TO KNOW
Antidepressant: A type of drug given to treat eating disorders as well as mood disorders like anxiety and depression.
Binge: An episode of eating in which a person consumes a larger amount of food within a limited period of time than most people would eat in similar circumstances.
Cognitive-behavioral therapy (CBT): An approach to therapy that aims at changing distorted thinking patterns, beliefs, and behaviors in order to change the patient's feelings.
Diuretic: A type of drug that increases the body's production of urine. Some people with bulimia take diuretics in order to lose weight by reducing the amount of water in the body.
Hall, Lindsey, and Leigh Cohn. Bulimia: A Guide to Recovery. 5th ed. Carlsbad, CA: Gürze Books, 1999.
Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: HarperPerennial, 1999.
Bakalar, Nicholas. “Therapies: Family Sessions Found to Help Treat Bulimia.” New York Times, September 4, 2007. Available online at http://www.nytimes.com/2007/09/04/health/04ther.html?_r=1&sq=bulimia&st=nyt&adxnnl=1&oref=slogin&scp=2&adxnnlx=1207166511-3dUW3ny1e8NabVf2POt6Ow (accessed March 2, 2008).
National Eating Disorders Association (NEDA). Bulimia Nervosa. http://www.edap.org/p.asp?WebPage_ID=286&Profile_ID=41141.
Public Broadcasting Service (PBS). Perfect Illusions: Eating Disorders and the Family. http://www.pbs.org/perfectillusions/index.html. This is the companion website to a PBS series of programs on bulimia and other eating disorders.
Something Fishy: Website on Eating Disorders. http://www.something-fishy.org/