BULIMIA NERVOSA

The most important feature in bulimia nervosa is the occurrence of episodes of binge eating. During these episodes, the individual consumes a large amount of food. These episodes of overeating are also associated with a sense of loss of control on the part of the patient. Once the eating has begun, the individual feels unable to stop until a large amount, often an excessive amount, has been eaten. However, patients with bulimia nervosa are able to stop eating if they are interrupted by the unexpected arrival of some individuals. After the overeating, individuals with bulimia nervosa engage in inappropriate behavior to avoid weight gain, such as deliberate vomiting or the abuse of laxatives. In addition, they may misuse water pills, fast for long periods, or engage in strenuous exercise after eating binges.

To establish a diagnosis of bulimia nervosa, the overeating episodes must occur at least twice a week for 3 months and must be accompanied by the behavior designed to avoid gaining weight. In addition, patients with this condition must exhibit an overconcern with their body's shape and weight; that is, they tend to associate much of their self-esteem with how much they weigh. It is important to keep in mind that simple binge eating at times, which is common, does not meet the criteria for bulimia nervosa. There must be the additional sense of lack of control, the overconcern with bodily appearance, and the recurrent behavior designed to lose the weight that may have been gained. There seems to be a high incidence of psychiatric disorder among bulimic patients. Such conditions as anxiety and depression, drug and alcohol abuse, and personality disorders are common.

The cause of bulimia nervosa is uncertain. We do know, however, that it is more common in adolescent girls or young adult women. A personal or family history of obesity and/or depression also appears to be a risk factor, and such factors as society's preoccupation with slimness and physical fitness may also play a role. Bulimia nervosa is 10 times more common among women. It also occurs more frequently in certain occupations, such as modeling, and certain sports, such as wrestling, running, and horse racing. There may be an association between sexual abuse as a child and bulimia nervosa; however, this has not been scientifically determined.

Bulimia nervosa is associated with a number of physical abnormalities secondary to the condition. These include the development of dehydration, as well as abnormal laboratory test results, caused by deliberate vomiting or the use of laxatives or water pills. Women who have this disorder are more likely to have menstrual problems, and in particular, individuals who engage in self-induced vomiting for many years may develop dental caries, especially of the upper front teeth. The acid from the stomach seems to soften the enamel, which in time disappears, so that the teeth chip more easily and may become smaller. It also may be that this condition is associated with an enlarged stomach and a slowed emptying of the stomach, both of which may increase the likelihood that the individual may be able to tolerate binge eating.

Bulimia nervosa usually occurs after a young woman who sees herself as overweight starts a diet, and after some early success with the diet begins to overeat. She then becomes distressed by her lack of control and her fear of gaining weight, and decides to make up for the overeating by causing vomiting or taking laxatives, usually having heard about these things from her friends or from media reports about eating disorders. After determining that she can successfully induce vomiting, she may feel pleased for awhile that she can eat large amounts and not gain weight. However, the disease is progressive and the binge eating usually increases in size and frequency, and often the sense of lack of control increases as well.

Binge eating tends to occur in late afternoon or evening and almost always occurs in a secretive manner, usually while the patient is alone. Studies suggest that the typical binge meal contains 1000 or more calories consisting of sweet, high-fat foods that are usually eaten for dessert, such as ice cream, cookies, cake, and candy. The behavior designed to avoid gaining weight usually starts right after the meal is eaten. Some individuals who have bulimia nervosa enjoy being around food whether they are eating or not. They enjoy preparing food for others, enjoy going to restaurants, and often enjoy working in areas where food is prepared. Whenever evaluating someone for bulimia nervosa, it is very important to obtain a specific history to uncover any behavior that might be life threatening, such as the use of water pills, amphetamines, diet pills, laxatives, and enemas.

The goal of treatment in bulimia nervosa is very simple. It is to decrease and then to end the binge eating and the inappropriate behavior afterwards designed to lose weight, as well as to help patients realize that self-esteem should be more appropriately based on factors other than their actual body weight. In general, patients with bulimia nervosa are much easier to treat than those with anorexia nervosa, because the patient with bulimia generally recognizes that there is a problem, so the struggles for control so often seen with anorexic patients are not seen with these individuals. The most common treatment at this time is a combination of cognitive and behavioral therapy. The cognitive component of the therapy concentrates on the abnormal thinking individuals may have about weight, and hopefully allows them to recognize that their self-image is based on other factors. Cognitive or behavioral therapy can be given either in individual sessions or as a group. The behavior aspect of this therapy may also involve positive feedback for desired behavior.

The other commonly used treatment has been drug therapy, particularly with antidepressant medication. Although it was originally thought that antidepressants would be used to treat the depression that was frequently seen among these patients, we have now seen a number of patients without significant depression who have benefited from antidepressant therapy. The most popular antidepressant drug for treating bulimia nervosa is fluoxetine (Prozac), administered at a dosage of 60 mg a day. It has been studied in many large trials and appears to be effective compared with other alternatives.

There are other special examples of bulimic patients, some of whom may be diabetic and who may purge themselves by omitting insulin dosages. In such particularly hard-to-treat cases, hospitalization may be required. It is important to keep in mind that the consequences of the binge eating and the attempts at purging can in many cases be life threatening.

• You should eat your meals with family members and not eat alone. This will decrease the likelihood of excessive eating.
• Because depression and stress may play a role in the overeating and binge pattern, it is important to reduce stress, perhaps by means of relaxation training or meditation.
• You should contact your physician if any significant mood disorders or suicidal thoughts develop.

• You should not go shopping for food when you are already hungry. It is best to have a meal and then go shopping, and it might be a good idea to have someone go shopping with you to decrease the likelihood of buying more of the high-calorie, less nutritious food.
• You should not take any medications without talking to your doctor. You should particularly avoid the use of so-called diet pills, which are usually high in caffeine or contain amphetamines. You should also not use laxatives or enemas unless instructed to do so.
• You should not overexercise. When exercising, it should be of moderate intensity and should be done in the company of someone else to provide some limits to the tendency to overexercise as a way of purging.

• If you notice any of the physical complications related to this condition that were previously mentioned.
• If you are feeling the urge to overeat or binge and are unable to control it.

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