People eat for many reasons that have little or nothing to do with being hungry, as is with bulimia nervosa. Having lots of food around can trigger munching, as can being with family and friends. Holidays, festivals, parties, and other cultural practices may require eating. Attempts to change one's body image can lead to a change in eating habits.

When dieting to an unhealthy body weight is promoted by current fashion trends fuels sales campaigns for special foods, diet plans, books, and fitness activities. Participating in these fads may be harmless, but sometimes a simple diet can lead to something more serious. Eating disorders involve severe disturbances in eating behavior, such as extreme reduction of food intake or even severe overeating, as well as feelings of distress or excessive concern about body weight and appearance.

Eating disorders frequently occur along with other psychiatric disorders such as mood disorders, substance abuse, and anxiety disorders. In addition, people with eating disorders may experience many physical health problems. Recognition of eating disorders as real and treatable diseases, therefore, is critically important.

Prevalence of Bulimia Nervosa

An estimated 1 to 4 percent of females will have bulimia nervosa sometime in their lifetime. Like anorexia nervosa, bulimia nervosa is ten times more common in females than males. This is thought to reflect greater societal emphasis on looks and thinness in females. Nevertheless, males may suffer from bulimia nervosa or a related condition known as muscle dysmorphia that also involves dissatisfaction with appearance.

Symptoms of Bulimia Nervosa

Symptoms of bulimia nervosa include binge eating — eating a substantially greater amount of food in a period of time (less than 2 hours) than most people would eat under similar circumstances. This bingeing may be planned in advance or may begin spontaneously.

During a binge, the individual usually eats rapidly, until uncomfortably full. They often feel a lack of control over their eating, which can be dissociative. The bingeing is often triggered by unhappy moods, and may be temporarily comforting.

Bingeing is then followed by an inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise. Vomiting is the most common form of purging (90% of bulimics), as it brings immediate physical relief and reduces fears of weight gain. Men with bulimia nervosa are less likely to vomit and more likely to exercise excessively (click here for a true story).

For a diagnosis of bulimia nervosa, the binge eating and inappropriate compensatory behaviors both must occur at least twice a week for three months. The bulimic's self-evaluation is unduly influenced by body shape and weight.

DSM-IV-TR Classification

Bulimia nervosa also has two subtypes:

Purging type is characterized by regular use of self-induced vomiting or the misuse of laxatives, diuretics, or (rarely) enemas. This type is more common and associated with more problems, including histories of childhood sexual abuse.

Non-purging type involves compensating for binge eating by excessive exercise or fasting but not by purging. People with bulimia nervosa are on average within the normal range for their age and height. However, like individuals with anorexia, they may fear gaining weight, desire to lose weight and feel extremely dissatisfied with their bodies. People with bulimia nervosa often binge and purge in secrecy, feeling disgusted and ashamed when they binge, yet relieved once they purge.

Medical Complications of Bulimia Nervosa

• Enlargement of the salivary glands (which can cause puffy cheeks)
• Dental enamel erosion (which can cause visibly shorter teeth)
• Excess gag reflex from repeated vomiting
• Electrolyte imbalances with associated serious medical consequences
• Ruptures of esophagus or stomach occasionally occur and in rare cases lead to death

Treatment of Bulimia Nervosa

The primary goal of treatment for bulimia nervosa is to reduce or stop binge eating and purging behavior. Nutritional education, psychotherapy, family intervention, and medication are often used. The goals of treatment usually include the establishment of regular, non-binge meals, improvement in attitudes related to the eating disorder, encouragement of healthy but not excessive exercise, and resolution of co-occurring conditions such as depression or anxiety disorders.

Individual psychotherapy (especially cognitive-behavioral or interpersonal psychotherapy), group psychotherapy that uses a cognitive-behavioral approach, and family or marital therapy have been reported to be effective. Psychiatric medications, primarily antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), have been found helpful for people with bulimia nervosa, particularly in patients with depression or anxiety, or those who have not responded adequately to psychotherapy alone. These medications also may help prevent relapse.

Article edited by M. Williams, Ph.D.
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