This page contains information on Bulimia nervosa which I pulled off the web. Authors and sight address included when available.
Mentalhealth.com
mamashealth.com
What is bulimia?
Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the 'fattening" effects of ingested food. The term should be restricted to the form of the disorder that is related to anorexia nervosa by virtue of sharing the same psychopathology. The age and sex distribution is similar to that of anorexia nervosa, but the age of presentation tends to be slightly later. The disorder may be viewed as a sequel to persistent anorexia nervosa (although the reverse sequence may also occur). A previously anorexic patient may first appear to improve as a result of weight gain and possibly a return of menstruation, but a pernicious pattern of overeating and vomiting then becomes established. Repeated vomiting is likely to give rise to disturbances of body electrolytes, physical complications (tetany, epileptic seizures, cardiac arrhythmias, muscular weakness), and further severe loss of weight.
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
B. eating, in a discrete period of time (e.g., within any 2-hour
period), an amount of food that is definitely larger than most
people would eat during a similar period of time and under similar
circumstances
C. a sense of lack of control over eating during the episode (e.g.,
a feeling that one cannot stop eating or control what or how much
one is eating)
D. Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting; misuse of
laxatives, diuretics, enemas, or other medications; fasting; or
excessive exercise.
E. The binge eating and inappropriate compensatory behaviors both
occur, on average, at least twice a week for 3 months.
F. Self-evaluation is unduly influenced by body shape and weight.
G. The disturbance does not occur exclusively during episodes of
Anorexia Nervosa.
What causes bulimia?
There is currently no definite known cause of bulimia. Researchers
believe it begins with dissatisfaction of the person's body and
extreme concern with body size and shape. Usually individuals
suffering from bulimia have low self-esteem, feelings of
helplessness and a fear of becoming fat
Medical complications?
Erosion of tooth enamel because of repeated exposure to acidic
gastric contents.
Dental cavities, sensitivity to hot or cold food.
Swelling and soreness in the salivary glands (from repeated
vomiting).
Stomach ulcers.
Ruptures of the stomach and esophagus.
Abnormal buildup of fluid in the intestines.
Disruption in the normal bowel release function.
Electrolyte imbalance.
Dehydration
Irregular heartbeat and in severe cases heart attack
A greater risk for suicidal behavior
Decrease in libido
Eating uncontrollably, purging, strict dieting, fasting, vigorous
exercise,
Vomiting or abusing laxatives or diuretics in an attempt to lose
weight. Vomiting blood
Using the bathroom frequently after meals.
Preoccupation with body weight
Depression or mood swings. Feeling out of control.
Swollen glands in neck and face
Heartburn, bloating, indigestion, constipation
Irregular periods
Dental problems, sore throat
Weakness, exhaustion, bloodshot eyes
Most sufferers will first go to their general practitioner. He may
well have a good knowledge of the local possibilities for
appropriate treatment. If specialist help is needed he should be
consulted as to choice of person and place. Another source of
unbiased advice is the Eating Disorders Association.
The N.H.S. has a number of eating disorder units often based on
teaching hospitals. Many of these are excellent but the quality is
very patchy. They often have long waiting lists and it may take
several months to wait for an assessment and longer to start an
agreed course of treatment. Your general practitioner should be
able to find out what the situation is locally quite easily.
The private sector also runs eating disorder units and many of
these are also of good quality. However inpatient stays frequently
run to several months so cost may be high. For most people medical
insurance is necessary. The area where you live may not have an
eating disorder unit run by the N.H.S. If this is so the N.H.S. may
buy treatment from the private sector under the Extra Contractual
Referral scheme. Assistance will be needed from your general
practitioner and from the admitting hospital but in practice this
means that the area health authority may pay for private care on a
private unit of your and the GP's choice.
WHAT ARE SPECIFIC TREATMENTS FOR PATIENTS WHO HAVE BULIMIA WITHOUT WEIGHT LOSS?
Some experts recommend a stepped approach to patients with bulimia,
which may follow these stages, depending on the severity and
response to initial treatments:
Support groups.
This is the least expensive approach and may be
helpful for patients who have mild conditions with no health
consequences.
Cognitive-behavioral therapy (CBT)
along with nutritional therapy
is the preferred first treatment for bulimia that does not respond
to support groups.
Drugs.
The drugs used for bulimia are typically antidepressants known as
serotonin-reuptake inhibitors (SSRIs). A combination of CBT and
SSRIs is very effective if CBT is not helpful alone.
Patients with bulimia rarely need hospitalization except under the
following circumstances:
Binge-purge cycles have led to anorexia.
Drugs are needed for withdrawal from purging.
Major depression is present.
Cognitive-behavioral therapy (CBT) is the first-line of therapy for
most patients with bulimia. Another beneficial approach is to
employ nutritional therapy that is aimed at reframing the patient's
view of healthy eating behaviors. Interpersonal therapies may be
tried if CBT fails.
Antidepressants. Because of the high incidence of depression in
patients with bulimia, antidepressant medication is often
recommended for patients who have normal weight or for those who
are overweight. The most common antidepressants prescribed for
bulimia are selective serotonin reuptake inhibitors (SSRIs). They
include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),
venlafaxine (Effexor), and fluvoxamine (Luvox). Prozac has been
approved for bulimia and is considered the drug of choice, although
many other SSRIs are probably as effective. Studies suggest that
SSRIs may reduce binge eating by 67% and vomiting by 56%. (Adding
cognitive-behavioral therapy improves success rates.
If the drugs are not effective, the physician should be sure it is
not because the patient is vomiting after taking the medication.
Some experts believe that these agents should be continued even
after symptoms have improved in order to restore healthy brain
chemical balances.
Agents to Prevent Vomiting. In one study, ondansetron, a drug that
prevents vomiting, reduced the binge-purge episodes by half. The
drug may cause depression in people already on SSRI antidepressants.
More studies are needed.
Sibutramine. Sibutramine (Meridia) is a drug used for weight loss. It
does so by keeping two important brain chemicals, serotonin and
norepinephrine, in balance, which helps to increase metabolism.
Some evidence suggests that the actions of this drug may be useful
for people who binge. Note, however, that in bulimic patients this
agent should be used only for those with normal or above normal
weight and never for those who are anorexic.
Inositol. Inositol is a B vitamin that is being investigated for
bipolar, anxiety, and depression. A 2001 study suggests that it may
have benefits for bulimic patients.
Hypnosis. A study on women with bulimia showed that they had a high
susceptibility to hypnosis, suggesting that it might be beneficial
as part of their treatment. People with anorexia, on the other hand,
seem to be very resistant to the state of vulnerability required in
this process.
Light Therapy. Some researchers have noted an association between
bulimia and seasonal affective disorder (depression that
intensifies in the darker winter months); this suggests that
therapy using intense directed light may be useful. Studies report,
however, that while light therapy relieves depression, it has
little effect on binge-purging behavior. Some experts suggest it
may be more useful combination with medication and psychotherapy.
Guided Imagery. A technique called guided imagery reduced frequency
of binges and vomiting by almost 75% in one study; this method uses
audio tapes to evoke images that will reduce stress and help achieve
specific goals.
Breast Reduction Surgery. Although women with eating disorders are
ordinarily disqualified from plastic surgery, two small studies
reported that in women whose bulimia was triggered by over-sized
breasts, reduction surgery was effective in resolving the eating
disorder.
What causes eating disorders?
There are many theories and no one simple answer that covers everyone. For any particular person, some or all of the following factors will be woven together to produce starving, stuffing, and purging.
Biological factors
Temperament seems to be, at least in part, genetically determined. Some personality types
(obsessive-compulsive and sensitive-avoidant, for example) are more vulnerable to eating disorders
than others. New research suggests that genetic factors predispose some people to anxiety,
perfectionism, and obsessive-compulsive thoughts and behaviors. These people seem to have more than
their share of eating disorders. In fact, people with a mother or sister who has had anorexia nervosa
are 12 times more likely than others with no family history of that disorder to develop it themselves.
They are four times more likely to develop bulimia. (Eating Disorders Review. Nov/Dec 2002)
Studies reported in the New England Journal of Medicine (3/03) indicate that for some, but not all,
people heredity is an important factor in the development of obesity and binge eating.
Also, once a person begins to starve, stuff, or purge, those behaviors in and of themselves can alter
brain chemistry and prolong the disorder. For example, both undereating and overeating can activate
brain chemicals that produce feelings of peace and euphoria, thus temporarily dispelling anxiety and
depression. In fact some researchers believe that eating disordered folks may be using food to
self-medicate painful feelings and distressing moods.
Psychological factors
People with eating disorders tend to be perfectionistic. They have unrealistic expectations of
themselves and others. In spite of their many achievements, they feel inadequate, defective, and
worthless. In addition, they see the world as black and white, no shades of gray. Everything is either
good or bad, a success or a failure, fat or thin. If fat is bad and thin is good, then thinner is
better, and thinnest is best -- even if thinnest is sixty-eight pounds in a hospital bed on life
support.
Some people with eating disorders use the behaviors to avoid sexuality. Others use them to try to take
control of themselves and their lives. They are strong, usually winning the power struggles they find
themselves in, but inside they feel weak, powerless, victimized, defeated, and resentful.
People with eating disorders often lack a sense of identity. They try to define themselves by
manufacturing a socially approved and admired exterior. They have answered the existential question,
"Who am I?" by symbolically saying "I am, or I am trying to be, thin. Therefore, I matter."
People with eating disorders often are legitimately angry, but because they seek approval and fear
criticism, they do not know how to express their anger in healthy ways. They turn it against themselves
by starving or stuffing.
Family factors
Some people with eating disorders say they feel smothered in overprotective families. Others
feel abandoned, misunderstood, and alone. Parents who overvalue physical appearance can unwittingly
contribute to an eating disorder. So can those who make critical comments, even in jest, about their
children's bodies.
These families tend to be overprotective, rigid, and ineffective at resolving conflict. Sometimes
mothers are emotionally cool while fathers are physically or emotionally absent. At the same time,
there are high expectations of achievement and success. Children learn not to disclose doubts, fears,
anxieties, and imperfections. Instead they try to solve their problems by manipulating weight and
food.
In addition, research suggests that daughters of mothers with histories of eating disorders may be at
higher risk of eating disorders themselves than are children of mothers with few food and weight
issues.
According to a report published in the April 1999 issue of the International Journal of Eating
Disorders, mothers who have anorexia, bulimia, or binge eating disorder handle food issues and weight
concerns differently than mothers who have never had eating disorders.
Patterns are observable even in infancy. They include odd feeding schedules, using food for rewards,
punishments, comfort, or other non-nutritive purposes, and concerns about their daughters' weight.
Still to be determined is whether or not daughters of mothers with eating disorders will themselves
become eating disordered when they reach adolescence.
Social factors
Sometimes appearance-obsessed friends or romantic partners create pressure that encourages
eating disorders. Ditto for sorority houses, theatre troupes, dance companies, school cliques, and
other situations where peers influence one another in unhealthy ways.
People vulnerable to eating disorders also, in most cases, are experiencing relationship problems,
loneliness in particular. Some may be withdrawn with only superficial or conflicted connections to
other people. Others may seem to be living exciting lives filled with friends and social activities,
but later they will confess that they did not feel they really fit in, that no one seemed to really
understand them, and that they had no true friends or confidants with whom they could share thoughts,
feelings, doubts, insecurities, fears, hopes, ambitions, and so forth. Often they desperately want
healthy connections to others but fear criticism and rejection if their perceived flaws and
shortcomings become known.
Media factors
People in western countries are flooded by media words and images. An average U.S. child, for example, watches more than 21 hours of TV each week plus dozens of magazines and many movies every year. In those media, happy and successful people are almost always portrayed by actors and models who are young, toned, and thin. The vast majority are stylishly dressed and have spent much time on hair styles and makeup.
Factoid: According to Health magazine, April 2002, 32% of female TV network characters are underweight, while only 5% of females in the U.S. audience are underweight.
In contrast, evil, stupid, or buffoonish people are portrayed by actors who are older, frumpier, unkempt, perhaps physically challenged. Many are fat.
Factoid: Again according to Health magazine, only 3% of female TV network characters are obese, while 25% of U.S. women fall into that category.
Most people want to be happy and successful, states that require thought, personal
development, and usually hard work. The media, especially ads and commercials for appearance-related
items, suggest that we can avoid the hard character work by making our bodies into copies of the icons
of success.
Reading between the lines of many ads reveals a not-so-subtle message -- "You are not acceptable the
way you are. The only way you can become acceptable is to buy our product and try to look like our
model (who is six feet tall and wears size four jeans -- and is probably anorexic). If you can't quite
manage it, better keep buying our product. It's your only hope."
The differences between media images of happy, successful men and women are interesting. The women,
with few exceptions, are young and thin. Thin is desirable. The men are young or older, but the heroes
and good guys are strong and powerful in all the areas that matter -- physically, in the business
world, and socially. For men in the media, thin is not desirable; power is desirable. Thin men are
seen as skinny, and skinny men are often depicted as sick, weak, frail, or deviant.
These differences are reflected in male and female approaches to self-help. When a man wants to improve
himself, he often begins by lifting weights to become bigger, stronger, and more powerful. When a woman
want to improve herself, she usually begins with a diet, which will leave her smaller, weaker, and
less powerful. Yet females have just as strong needs for power and control as do males.
Many people believe this media stereotyping helps explain why about ninety percent of people with
eating disorders are women and only ten percent are men.
In recent years it has become politically correct for the media to make some effort to combat eating
disorders. We have seen magazine articles and TV shows featuring the perils and heartbreak of anorexia
and bulimia, but these efforts seem weak and ineffective when they are presented in the usual context.
For example, how can one believe that a fashion magazine is truly motivated to combat anorexia when
their articles about that subject are surrounded by advertisements featuring anorexic-looking models?
How can one believe that the talk show hostess is truly in favor of strong, healthy female bodies when
she frequently prods her stick-like thighs and talks about how much she wants to lose weight from her
already scrawny body?
In May 1999, research was published that demonstrated the media's unhealthy affect on women's
self-esteem and body awareness. In 1995, before television came to their island, the people of Fiji
thought the ideal body was round, plump, and soft. Then, after 38 months of Melrose Place, Beverly
Hills 90210, and similar western shows, Fijian teenage girls showed serious signs of eating
disorders.
In another study, females who regularly watch TV three or more nights per week are fifty percent more
likely than non-watchers to feel "too big" or "too fat." About two-thirds of the TV-watching female
teens dieted in the month preceding the survey. Fifteen percent admitted vomiting to control their
weight. TV shows like the two mentioned above are fantasies, but all over the world young women, and
some not so young, accept them as instructions on how to look and act. That's really a shame.
An important question for people who watch TV, read magazines, and go to movies -- do these media
present images that open a window on the real world, or do they hold up a fun house mirror in which the
reflections of real people are distorted into impossibly tall, thin sticks (or impossibly muscular,
steroid-dependent male action figures)? Media consumers need to be wise consumers of visual images.
For more information on this topic, we recommend "Remote Control Childhood? Combatting the Hazards of
Media Culture," a book by Diane Levin.
Triggers
If people are vulnerable to eating disorders, sometimes all it takes to put the ball in motion
is a trigger event that they do not know how to handle. A trigger could be something as seemingly
innocuous as teasing or as devastating as rape or incest.
Triggers often happen at times of transition, shock, or loss where increased demands are made
on people who already are unsure of their ability to meet expectations. Such triggers might include
puberty starting a new school, beginning a new job, death, divorce, marriage, family problems, breakup
of an important relationship, critical comments from someone important, graduation into a chaotic,
competitive world, and so forth.
There is some evidence to suggest that girls who achieve sexual maturity ahead of peers, with the
associated development of breasts, hips, and other physical signs of womanhood, are at increased risk
of becoming eating disordered. They may wrongly interpret their new curves as "being fat" and feel
uncomfortable because they no longer look like peers who still have childish bodies.
Wanting to take control and fix things, but not really knowing how, and under the influence of a
culture that equates success and happiness with thinness, the person tackles her/his body instead of
the problem at hand. Dieting, bingeing, purging, exercising, and other strange behaviors are not random
craziness. They are heroic, but misguided and ineffective, attempts to take charge in a world that
seems overwhelming.
Sometimes people such as diabetics who must pay meticulous attention to what they eat become vulnerable
to eating disorders. A certain amount of obsessiveness is necessary for health, but when the fine line
is crossed, healthy obsessiveness can quickly become pathological.
Perhaps the most common trigger of disordered eating is dieting. It is a bit simplistic, but
nonetheless true, to say that if there were no dieting, there would be no anorexia nervosa. Neither
would there be the bulimia that people create when they diet, make themselves chronically hungry,
overeat in response to that hunger, and then, panicky about weight gain, vomit or otherwise purge to
get rid of the calories.
Feeling guilty and perhaps horrified at what they have done, they swear to "be good." That usually
means more dieting, which leads to more hunger, and so the cycle repeats again and again. It is
axiomatic in eating disorders treatment programs that the best way to avoid a binge is to never, never
allow oneself to become ravenously hungry. It is far wiser to be aware of internal signals and respond
to hunger cues early on by eating appropriate amounts of nourishing, healthy food.
Where can I get more information about bulimia and other eating disorders?
NEDIC
New National Toll-Free Number for NEDIC
1-866-NEDIC-20 (1-866-63342-20)
or 416-340-4156 in Toronto