"Bulimia," derived from the Greek words for "ox" and
"hunger," is a syndrome that includes two elements: 1) binge eating and
2) self-induced vomiting, laxative abuse, or other measures to avoid weight
gain (see Table 2). A specific criterion for bulimia is repeated episodes
of binge eating (an average of twice a week for 3 months), during which
patients feel that they cannot control their eating. Purging is not essential
to the diagnosis, but occurs in 80% of cases. The term "nervosa" was recently
added to "bulimia" to emphasize the features that it shares with anorexia
nervosa, primarily the relentless pursuit of lower weight and the morbid
fear of fatness. Patients with bulimia may be over, under, or at ideal body
weight, with normal weight range most common. A diagnosis of anorexia nervosa
takes precedence over bulimia if weight is below 85% of normal.
Like anorexia nervosa, bulimia nervosa usually begins by dieting. Dieters
tend toward bulimia rather than anorexia when their hunger overcomes
their attempt to restrict food and they begin binge eating, which is
not in itself abnormal in food deprivation when faced with abundant
nutrition. The clinical disorder emerges when a morbid fear of fatness
entrenches itself, and patients suffer psychological distress or medical
complications after binge eating and subsequent purging and especially
when binges are provoked by emotional distress rather than hunger.
Bingeing is promoted by restricting food early in the day (no breakfast,
salad for lunch), so an appetite builds that may not express itself
until late afternoon or evening, the most common times for bingeing.
In extreme cases, patients consume 10,000 to 30,000 calories a day and
binge throughout the day. The patient's social life becomes organized
around secret binge and purge episodes, requiring carefully timed entrances
and exits. In a substantial minority of patients, bulimic behavior is
part of a broader pattern of abnormally impulsive behavior, including
alcohol or other drug abuse, sexual promiscuity, and stealing.
Patients can develop bulimia at any age from the preteens to the 50's
with the peak onset of few years later than anorexia nervosa, 18-20
year old. Half of patients have a history of anorexia nervosa or an
anorexia-like episode. Bulimia may alternate with anorexia nervosa in
an irregular sequence over several decades.
Bulimia has diverse complications. Nonspecific abnormalities of gastric
emptying and bowel function can cause abdominal distention that may
worsen patients' distorted perception of their body size and increase
their desire to purge. Repeated regurgitation of gastric secretions
erodes the enamel on the lingual surfaces of teeth. Serious complications
include systemic hypokalemic alkalosis, leading to cardiac arrhythmias,
renal damage, and seizures. If patients use the emetic Ipecac, the emetine
that it contains can cause myocardial damage similar to viral myocarditis.
Most deaths among patients with bulimia are caused by arrhythmias or
Even after psychological treatment has succeeded in stopping their
binge/purge behavior, patients may have persistent esophageal reflux
that provokes unwanted vomiting for years.
Management of Bulimia Nervosa
After diagnosis and initial medical
assessment, many patients with bulimia nervosa can be treated as outpatients,
with a goal of gradually decreasing the frequency and severity of their
bingeing and purging. But some patients must have their behavior interrupted
abruptly by hospitalization, especially if severe and intractable or accompanied
by suicide plans or medical complications. Bulimia sufferers are usually
surprised and relieved to find that eating moderate quantities of food
three times a day does not make them fat, as they had feared.
After bingeing and purging is stopped and any medical complications
are treated, the focus of management turns to long-term inhibition of
binge/purge behavior with cognitive-behavioral therapy. As in management
of anorexia nervosa, the physician must recognize the commonly coexisting
psychiatric conditions. About 50% of bulimic patients benefit from an
antidepressant drug. Regular moderate exercise is helpful in both managing
stress and promoting a healthy body shape and composition. Both cognitive
behavioral psychotherapy, and interpersonal psychotherapy, have been
shown to produce significant enduring improvements, greater than antidepressants
alone. The disorder has a good outcome if treated vigorously.
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