Bulimia Nervosa (Binge-Purge Syndrome)

Basic Information

Bulimia or bulimia nervosa is an ailment where the patient's eating behavior is so disturbed that it can cause the onset of disease or debilitation. It is almost exclusively a disorder that affects women, with a female to male ratio of 9 to 1. The onset of the illness usually does not begin until the patient is 17, and most cases are diagnosed between ages 17--25, but a patient can present the first signs of this illness in her 30s or 40s even. Also adolescent girls can be affected. It affects approximately 1 to 4% of the U.S. population, with athletes (especially runners, wrestlers and horse racers), dancers and college students affected at a much higher ratio than the general public.

The cause of bulimia is not known but there are several factors that are believed to play a role. They include:

• cultural (where there is a cultural pressure to be slim, especially in Western society)
• psychological
• social
• physical

It is thought that these multi-factors usually in combination trigger the onset of the disease.

Society's overemphasis on slimness and preoccupation with the body's appearance cannot be underestimated as underlying causes for bulimia. A family history of depression or obesity could be another cause. Still yet, many believe in the correlation between sexual abuse as a child and bulimia, but this has yet to be proved.

Bulimia is defined by the binge-purge syndrome. The syndrome is episodic. During these episodes of binging, the patient eats a very large amount of food and she is unable to stop eating until an excessive amount has been consumed. The patient experiences an overwhelming loss of control during these over-eating binges and is unable to stop unless an outside influence intervenes such as the arrival of guests dropping in unexpectedly.

The purging begins after the binging has ended. This is done to avoid gaining weight yet the purging methods can be hazardous to the patient's health. Often the patient will resort to vomiting, abuse water pills, fast for an inappropriate period, misuse laxatives, or exercise in a vigorous manner that is out of proportion to her normal lifestyle. Thus it is a catch-22 situation -- the patient is usually anxious to present to the world that she is looking normal and leading a healthy life but to preserve that image secret unhealthy binging and purging tell a hidden tale of ill health and emotional distress.

Bulimia often starts with a woman who sees herself as overweight, begins to diet and after a period of accomplishment with the diet, starts a desperate cycle of overeating with an attendant loss of control. Yet at first the patient will believe the situation is under control even though it is not -- bulimia is a progressive disease and the binge-purging will become more excessive and more frequent. The binging takes place concealed from the eyes of others, often in the evening when "forbidden" or "evil" foods are consumed like high-fat foods or dessert-type sweets. But right after the meal, the desperate urge to begin purging begins.

Food is an issue to patients diagnosed with bulimia. There is a constant overinterest (though almost always unexpressed) in food. Often patients like to be around food, even if they do not eat it, spend a lot of time in restaurants, insist on preparing food for others and often work in places that specialize in food preparation. Ostensibly the patient perceives this preoccupation with food as an enjoyable situation and acceptable behavior, but in reality it soon becomes the source of stress and depression.

Symptoms

Besides the binge-purge behavioral pattern, and a family history that may involve sexual abuse, depression and obesity, there can be physical evidence that may help point to bulimia, especially if the patient is reluctant to admit the extent of her binge--purge behavior. These physical findings may include:

• loss of gag reflex
• corneal hemorrhages
• possible disorders of the gums or eroded enamel on the upper teeth
• salivary gland swelling
• Russell's sign -- or scars on the knuckles -- when vomiting is induced.

Diagnosis/Treatment

Bulimia is not particularly easy to diagnose. One of the reasons is that many people binge eat but that does not mean that they suffer from bulimia. A specific criteria must be met in order to make the diagnosis:

• The binge eating must be present at least twice a week for a period of at least three months and must have purging episodes which follow the binges in an attempt not to gain weight
• lack of control
• an obsessive concern about body appearance and weight directly tied to self-esteem

Two questions posed to patients will routinely help a health care provider diagnose the ailment. They are:

1. "Do you sometimes eat in secret?"
2. "Do you find your eating habits satisfactory?"

If the answer to the first question is yes and the answer to the second question is no, it is believed that there is an almost 90% specificity for bulimia nervosa.

Treatments vary modified by the behavior, physical condition and emotional/mental state of the patient. If you are diagnosed with bulimia, your health care provider can be of great help in having a non-judgmental, frank discussion with you about this disorder and will usually recommend counseling or therapy to control and/or change destructive behavior. Attendant psychological problems and addiction issues are often part of the make-up of the bulimic patient and must be addressed. Alcoholism, drug dependency, a high stress level, depression and even personality disorders are too often the rule and not the exception. If you are bulimic with any of these problems or issues, they must be treated as well.

Your health care provider will probably want to refer you to a nutritionist who can counsel you about bulimia and follow up with your progress. A nutritionist may suggest that you plan your meals the previous day and keep a food diary so that you are not at the whim of totally unplanned cravings. It is also recommended that you do not shop for food on an empty stomach. And eating alone is discouraged. Stress must be reduced; relaxation techniques such as meditation introduced. In treating bulimia, cognitive therapy (in addition to behavioral therapy) is often successful in shifting the patient's unhealthy thinking patterns so that the patient can see that self-esteem and self-image is inclusive of many factors, the least of which may be perceived body appearance or "slimness". Peer groups such as the 12-step program Overeaters Anonymous (OA) can provide spiritual and practical support from other members who have also been diagnosed with bulimia. Antidepressants have proved beneficial in the treatment of bulimia, one of the many reasons being that it corrects electrolyte abnormalities.

Physical problems resulting from this illness are not uncommon and your health care provider will want to check for signs of dehydration as well as adverse effects from overuse of laxatives and induced vomiting. Remember, this can be a life-threatening illness which in some difficult cases may require hospitalization. (Sometimes diabetics purge their insulin doses, putting themselves in danger.) It is not a disorder to take lightly. So if you feel you may have bulimia or an eating disorder, please see your health care provider promptly.

Additional Resource(s):

• Overeaters Anonymous
• Bulimic Society
• Each has local branches in every state.