Bulimia Nervosa 3

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Bulimia nervosa is an eating disordercharacterized by binge eating and purging or consuming a

large amount of food in a short amount of time, followed by an attempt to rid oneself of the food

consumed, usually by purging (vomiting) and/or by laxative, diuretics or excessive exercise.[1][2] Bulimia nervosa is nine times more likely to occur in women than men (Barker 2003).

Antidepressants, especially SSRIs, are widely used in the treatment of bulimia nervosa. (Newell

and Gournay 2000).

The term bulimia comes from Greek(boulmia; ravenous hunger), a compound

of(bous), ox +(lmos), hunger.[3] Bulimia nervosa was named and first described by

the British psychiatrist Gerald Russell in 1979.[4][5] Bulimia is strongly familial. Twin studies

estimate the heritability of syndromic bulimia to be 54 to 83%.[6][7]

Contents

[hide]

1 Signs and symptoms

o 1.1 Related disorders

2 Diagnosis

o 2.1 Pharmacological

o 2.2 Psychotherapy

o 2.3 Etiology

3 Epidemiology

4 See also

5 Notes

[edit]Signs and symptoms

These cycles often involve rapid and out-of-control eating, which may stop when the bulimic is

interrupted by another person or the stomach hurts from overextension, followed by self-induced

vomiting or other forms of purging. This cycle may be repeated several times a week or, in more

serious cases, several times a day,[8] and may directly cause:

Chronic gastric reflux after eating

Dehydration and hypokalemiacaused by frequent vomiting

Electrolyte imbalance, which can lead tocardiac arrhythmia,cardiac arrest, and even

death

Esophagitis, orinflammation of the esophagus

Boerhaave syndrome, a rupture in the esophageal wall due to vomiting

Oral trauma, in which repetitive insertion of fingers or other objects causes lacerations to

the lining of the mouth or throat

Gastroparesisor delayed emptying

Constipation
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Infertility

Enlarged glands in the neck, under the jaw line

Peptic ulcers

Callusesorscars on back of hands due to repeated trauma from incisors[9][10]

Constant weight fluctuations are common

The erosion on the lower teeth was caused by Bulimia. For comparison, the upper teeth were restored with

porcelain veneers.[11]

The frequent contact between teeth andgastric acid, in particular, may cause:

Severedental erosion

Perimolysis, or the erosion of tooth enamel[12]

Swollen salivary glands[12][13]

Constant vomiting can lead to gastroesophageal reflux

[14]

As with many psychiatric illnesses, delusions can occur with other signs and symptoms leaving

the person with a false belief that is not ordinarily accepted by others.[15]

The person may also suffer physical complications such as tetany, epileptic seizures, cardiac

arrhythmias and muscle weakness.(ICD-10)[citation needed].

People with bulimia nervosa may also exercise to a point that excludes other activities.[15]

[edit]Related disorders

Bulimics are much more likely than non-bulimics to have an affective disorder, such

asdepression,body dysmorphic disorder[16] orgeneral anxiety disorder: A 1985 Columbia

University study on female bulimics at New York State Psychiatric Institutefound 70% had

suffered depression some time in their lives (as opposed to 25.8% for adult females in a control

sample from the general population), rising to 88% for all affective disorders combined. [17] Another

study by the Royal Children's Hospital inMelbourne on a cohort of 2000 adolescents similarly

found that those meeting at least two of the DSM-IV criteria for bulimia nervosa oranorexia

nervosa had a sixfold increase in risk of anxiety and a doubling of risk for substance dependency.[18] Some sufferers of anorexia nervosa exhibit episodes of bulimic tendencies through purging
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(either through self-induced vomiting or laxatives) as a way to quickly remove food in their

system. [19] Bulimia also has negative effects on the sufferer's dental health due to the acid

passed through the mouth from frequent vomiting causing acid erosion, mainly on the posterior

dental surface.

[edit]Diagnosis

The onset of bulimia nervosa is often during adolescence, between 13 and 20 years of age, and

many cases have previously suffered obesity, with many sufferers relapsing in adulthood into

episodic binging and purging even after initially successful treatment and remission.[20]

According to Barker, "persons with bulimia are more able to live and interact in everyday chores

and tasks such as work and having relationships without the condition overly affecting their

abilities".[21]

Bulimia nervosa can be difficult to detect, compared to anorexia nervosa, because bulimics tend

to be of average or slightly above or below average weight. Many bulimics may also engage in

significantly disordered eating and exercising patterns without meeting the full diagnostic criteria

for bulimia nervosa.[22] The diagnostic criteria utilized by the Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV TR) published by theAmerican Psychiatric Association includes

repetitive episodes of binge eating (a discrete episode of overeating during which the individual

feels out of control of consumption) compensated for by excessive or inappropriate measures

taken to avoid gaining weight.[23]The diagnosis is made only when the behavior is not a part of

the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on

physical mass or appearance.

There are two sub-types of bulimia nervosa:

Purging type bulimics self-induce vomiting(usually by triggering the gag reflex or

ingesting emeticssuch as syrup of ipecac) to rapidly remove food from the body before it canbe digested, or use laxatives, diuretics, orenemas.

Non-purging type bulimics (approximately 6%8% of cases) exercise or fast excessively

after a binge to offset the caloric intake after eating. Purging-type bulimics may also exercise

or fast, but as a secondary form of weight control.[24]

[edit]Pharmacological

Some researchers have hypothesized a relationship to mood disorders and clinical trials have

been conducted with tricyclic antidepressants,[25]MAO inhibitors,mianserin,fluoxetine,[26]lithium

carbonate, nomifensine, trazodone, and bupropion. Research groups who have seen a

relationship to seizure disorders have attempted treatment with phenytoin, carbamazepine, andvalproic acid. Opiate antagonists naloxone and naltrexone, which block cravings for gambling,

have also been used.[27]

There has also been some research characterizing bulimia nervosa as an addiction disorder, and

limited clinical use oftopiramate, which blocks cravings for opiates, cocaine, alcohol and food. [28]

[edit]Psychotherapy
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There are several empirically-supported psychosocial treatments for bulimia nervosa. Cognitive

behavioral therapy(CBT), which involves teaching clients to challenge automatic thoughts and

engage in behavioral experiments (for example, in session eating of "forbidden foods") has

demonstrated efficacy both with and without concurrent antidepressant medication. Research

suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic

treatment for bulimia nervosa. One exception was a study that suggested that interpersonalpsychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects [29]. By

using CBT patients record how much food they eat and periods of vomiting with the purpose of

identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular

basis (Gelder, Mayou and Geddes 2005). Barker (2003) states that research has found 40-60%

of patients using cognitive behaviour therapy to become symptom free. He states in order for the

therapy to work, all parties must work together to discuss, record and develop coping strategies.

Barker (2003) claims by making people aware of their actions they will think of alternatives.[30]

[31] Researchers have also reported some positive outcomes for interpersonal psychotherapy

anddialectical behavior therapy.[32][33]

Maudsley Family Therapya.k.a. Family Based Treatment (FBT), developed at the MaudsleyHospital inLondon for the treatment of anorexia nervosa (AN) has been shown to have positive

results for the treatment of bulimia nervosa. FBT has been shown through empirical research to

be the most efficacious treatment of AN for patients under the age of eighteen and within three

years of onset of illness. The studies to date using FBT to treat BN have been promising.[34]

Some researchers have also claimed positive outcomes in hypnotherapytreatment.[35][36][37][38]The

Twelve-Step model ,used for chemically dependent individuals, was applied to bulimic patients

with good results. Researchers at [Ohio State University], in a preliminary study, incorporated the

twelve-step model in their treatment of bulimic women in an inpatient unit. They reported positive

outcomes. [39]

[edit]EtiologyMedia portrayals of an 'ideal' body shape are widely considered to be a contributing factor to

bulimia[1] (Barker 2003). A survey of 1518 year-old high school girls in Nadroga,Fiji found the

self-reported incidence of purging rose from 0% in 1995 (a few weeks after the introduction of

television in the province) to 11.3% in 1998.[40]

Brain-derived neurotrophic factor(BDNF) is under investigation as a possible mechanism. [41][42]

Through the cognitive and socio-cultural perspectives, indications towards the origin of bulimia

nervosa can be established. Fairburn et als cognitive behavioral model of bulimia nervosa

provides a chief indication of the cause of bulimia through a cognitive perspective, while the thin

ideal is particularly responsible for the etiology of bulimia nervosa through a socio-cultural

context. When attempting to decipher the origin of bulimia nervosa in a cognitive context,

Fairburn and et als cognitive behavioral model is often considered the golden standard. Fairburn

et als model discusses the process in which an individual falls into the binge-purge cycle and

thus develops bulimia. Fairburn et al argue that extreme concern with weight and shape coupled

with low self esteem will result in strict, rigid, and inflexible dietary rules. Accordingly, this would

lead to unrealistic restricted eating, which may consequently induce an eventual slip where the

individual commits a minor infraction of the strict and inflexible dietary rules. Moreover, the
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cognitive distortion due to dichotomous thinking leads the individual to binge. The binge

subsequently should trigger a perceived loss of control, promoting the individual to purge in hope

of counteracting the binge. However, Fairburn et al assert the cycle repeats itself, and thus

consider the binge-purge cycle to be self-perpetuating.

In contrast, Byrne and Mcleans findings differed slightly from Fairburn et als cognitive behavioral

model of bulimia nervosa in that the drive for thinness was the major cause of purging as a way of

controlling weight. In turn, Byrne and Mclean argued that this makes the individual vulnerable to

binging, indicating that it is not a binge-purge cycle but rather a purge-binge cycle in that purging

comes before binging. Similarly, Fairburn et als cognitive behavioral model of bulimia nervosa is

not necessarily applicable to every individual and is certainly reductionist. Everyone differs from

another, and taking such a complex behavior like bulimia and applying the same one theory to

everyone would certainly be invalid. In addition, the cognitive behavioral model of bulimia nervosa

is very cultural bound in that it may not be necessarily applicable to cultures outside of the

Western society. To evaluate, Fairburn et als model and more generally the cognitive explanation

of bulimia nervosa is more descriptive than explanatory, as it does not necessarily explain how

bulimia arises. Furthermore, it is difficult to ascertain cause and effect, because it may be thatdistorted eating leads to distorted cognition rather than vice versa.[43]

[44]

When exploring the etiology of bulimia through a socio-cultural perspective, the thin ideal

internalization is significantly responsible. The thin ideal internalization is the extent to which

individuals adapt to the societal ideals of attractiveness. Individuals first accept and buy into the

ideals, and then attempt to transform themselves in order to reflect the societal ideals of

attractiveness. J. Kevin Thompson and Eric Stice claim that family, peers, and most evidently

media reinforce the thin ideal, which may lead to an individual accepting and buying into the thin

ideal. In turn, Thompson and Stice assert that if the thin ideal is accepted, one could begin to feel

uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal setout by society. Thus, people feeling uncomfortable with their bodies may result in suffering from

body dissatisfaction, and may develop a certain drive for thinness. Consequently, body

dissatisfaction coupled with drive for thinness is thought to promote dieting and negative affects,

which could eventually lead to bulimic symptoms such as purging or binging. Binges lead to self-

disgust which causes purging to prevent weight gain.[45]

A study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is

Thompsons and Stices research. The aim of their study was to investigate how and to what

degree does media effect the thin ideal internalization. Thompson and Stice used randomized

experiments (more specifically programs) dedicated to teaching young women how to be more

critical when it comes to media, in order to reduce thin ideal internalization. The results showed

that by creating more awareness of the medias control of the societal ideal of attractiveness, the

thin ideal internalization significantly dropped. In other words, less thin ideal images portrayed by

the media resulted in less thin ideal internalization. Therefore, Thompson and Stice concluded

that media effected greatly the thin ideal internalization.

[46]
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[edit]Epidemiology

There is little data on the prevalence of bulimia nervosa in-the-large, on general populations.

Most studies conducted thus far have been on convenience samples from hospital patients, high

school or university students. These have yielded a wide range of results: between 0.1% and

1.4% of males, and between 0.3% and 9.4% of females.[47]

Studies on time trends in theprevalence of bulimia nervosa have also yielded inconsistent results.[48] According to Gelder,

Mayou and Geddes (2005) bulimia nervosa is prevalent between 1 and 2 per cent of women

aged 1540 years. Bulimia nervosa occurs more frequently in developed countries (Gelder,

Mayou and Geddes 2005).
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