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 suicide.

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.

Next Page | Previous Page | Title Page