Bulimia Nervosa

What is bulimia nervosa?

Bulimia nervosa (often just called bulimia) is a condition where you think a lot about your body weight and shape. It affects your ability to have a 'normal' eating pattern. Bulimia is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia nervosa, you are most likely to be normal weight or even overweight.

How do I know if I have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder and you should see your doctor:

• Do you make yourself sick because you are uncomfortably full?
• Do you worry that you've lost control over how much you eat?
• Have you recently lost more than 6 kg (about one stone) in the past three months?
• Do you believe you're fat when others think you're thin?
• Would you say that food dominates your life?

Who gets bulimia nervosa?

Bulimia mainly affects women aged 16-40. It most commonly starts around the age of 19 years. It affects around 8 in 100 women in the UK. Bulimia sometimes develops in men and children. Women are 10 times more likely to develop bulimia than men. However, bulimia is becoming more common in boys and men. Bulimia is more common than anorexia nervosa.

There may be some genetic factor, as the risk of developing bulimia in close relatives of people with bulimia is four times greater than in the general population.

What are the symptoms of bulimia nervosa?

Bingeing and purging are the main symptoms and are usually done in secret.

• Bingeing means that you have repeated episodes of eating large amounts of foods and/or drinks. For example, you may eat a whole large tub of ice cream or two packets of biscuits even if you are not hungry. You feel out of control and unable to stop eating. Binge eating is often done very quickly until you feel physically uncomfortable. This happens not just on one occasion, but regularly. Eating patterns typically become chaotic.
  
  
• Purging means that you try and counteract the 'fattening' effects of the food from the bingeing. Self-induced vomiting (making yourself sick) after a bout of bingeing is the most well-known, but not all people with bulimia do this. Other purging methods include taking lots of laxatives, extreme exercise, extreme dieting or even periods of complete starvation, taking diuretics (water tablets) or taking other medicines such as amfetamines.

The reasons why you binge eat and then purge may not be easy to explain. Part of the problem may be due to a fear of getting fat, although it is often not just as simple as that. All sorts of emotions, feelings and attitudes may contribute. The physical act of bingeing and purging may be a way of dealing with your emotions in some way.

What are the physical problems caused by bulimia?

These are caused by the unusual eating habits and the methods used to purge the body of food (such as vomiting or the excessive use of laxatives). Physical problems do not always develop. They are more likely if you binge and purge often. One or more of the following may develop:

Irregular periods

Many people have irregular periods as hormone levels can be affected by poor diet. Periods may even stop all together or you may find that your periods have never started, especially if you started having eating problems when you were younger.

Chemical imbalances in the body

These are caused by either repeated vomiting or excess use of laxatives. For example, a low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to tetany (muscle spasms).

Bowel problems

These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.

Swelling of hands, feet and face

This is usually due to fluid disturbances in the body. The saliva glands in the face can sometimes swell due to the frequent vomiting.

Teeth problems

These can be caused by the acid from the stomach rotting away the enamel as a result of repeated vomiting.

Depression

It is fairly common to feel low when you have bulimia. Some people even become depressed, which can respond well to treatment. It is important to talk about any symptoms of depression you may have. Many people find they become more moody or irritable.

Psychological problems

These are very common and include feelings of guilt and disgust after bingeing and purging. Poor self-esteem, and mood swings, are common.

What causes bulimia nervosa?

The exact cause is not clear. Some people blame the media and the fashion industry which portray the idea that it is fashionable to be slim. This can put pressure on some people to try to be slim which can then lead to an eating disorder.

There may be some genetic factor to developing bulimia, which is triggered by stressful or traumatic life experiences. For example, some people with bulimia have had a childhood where there were frequent family problems with arguments and criticism at home. Some people with bulimia have been abused as a child.

Sometimes bulimia is also associated with some other psychological problem. (That is, the bulimia is sometimes just a part of a broader mental health problem.) For example, there is a higher than average rate of bulimia in people with anxiety disorders, obsessive compulsive disorder, depression, post-traumatic stress disorder and some personality disorders.

A chemical called serotonin which is in parts of the brain is thought to have something to do with bulimia. In some way one or more of the above factors, or even other unknown factors, may lead to a low level of serotonin.

Are there any tests done for bulimia?

Although there is not an actual test to diagnose bulimia, your doctor may wish to undertake some blood tests. These are usually done to check your kidney function and potassium levels.

What are the treatments for bulimia nervosa?

The aim of treatment is to:

• Reduce risk of harm which can be caused by bulimia.
• Encourage healthy eating.
• Reduce other related symptoms and problems.
• Help people become both physically and mentally stronger.

Many people with bulimia who see their GP will be referred to a specialist mental health team. Members of the team may include psychiatrists, psychologists, nurses, dietitians and other professionals. If you have more severe bulimia you may be referred to a specialist eating disorder unit.

The sort of treatments that may be offered include the following:

Help with eating

It is best if you have regular meals; even if you only eat small meals. It is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other people) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary in order to write down all the food that you eat.

Psychological ('talking') treatments

Cognitive behavioural therapy (CBT) is the most commonly used psychological treatment for bulimia. It helps you to look at the reasons why you developed bulimia, aims to change any false beliefs that you have about your weight and body, and it helps to show you how to deal with emotional issues. Talking treatments take time and usually require regular sessions over several months.

Treatment may also involve other members of your family going to meetings to discuss any family issues. However, CBT does not suit everyone. About a third of people drop out before finishing the course. Other forms of psychological treatments may also be used. For example, cognitive analytic therapy (CAT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy.

Medication

A medicine may be advised by your doctor. The most commonly used medicines are selective serotonin reuptake inhibitor (SSRI) antidepressants. These are used to treat depression but, in higher doses, one called fluoxetine can reduce the urge for bingeing or purging. These are not usually recommended if you are younger than 18 years old.
[/h3]Treatment of any physical or teeth problems that may occur[/h3]This may include taking potassium supplements, dental care and not using laxatives.

Self-help measures

There are a number of self-help books and manuals available. These provide strategies in how to cope with, and overcome, bulimia. Some people find these very helpful and prefer them to 'formal' treatment. (The organisation called 'beat' - details at the end - may be able to suggest current titles.) It is certainly worth trying a self-help manual if there is a waiting list or difficulty in getting psychological treatment.

What is the outlook (prognosis)?

Bulimia is the sort of condition that is difficult to cure fully 'once and for all'. Many people improve with treatment, but bad spells (relapses) may recur from time-to-time in some cases. Many people find they still have issues with food, even after treatment, but they are more in control and can lead happier, more fulfilled lives.

Studies suggest that 10 years after a diagnosis of bulimia about 5 in 10 people are well, about 2 in 10 people still have bulimia, and about 3 in 10 people are somewhere in the middle. However, the recent study about CBT treatment (cited at the end) suggests that with good quality CBT, the outlook is probably even better than these 'overall' figures. It is very unusual to die from bulimia.

Further help and information

This leaflet is just a brief introduction to bulimia. For further help, information, resources, 'self-help guides', etc, it is best to see your doctor first. The following may also be of help:

beat

103 Prince of Wales Road, Norwich, NR1 1DW
Tel: 08456 341414 Web: www.b-eat.co.uk
beat is the working name of the Eating Disorders Association. It provides helplines for adults and young people, online support and a UK-wide network of self-help groups to help people beat their eating disorder.

Institute of Psychiatry/Maudsley Hospital

Web: www.iop.kcl.ac.uk/sites/edu/?id=131
This site has good information on medical complications of eating disorders and is kept up-to-date with research developments.

References

• Eating disorders, Clinical Knowledge Summaries (October 2009)
• Fairburn CG, Cooper Z, Doll HA, et al; Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up. Am J Psychiatry. 2008 Dec 15. [abstract]
• Hay PJ, Bacaltchuk J, Stefano S; Psychotherapy for bulimia nervosa and binging. Cochrane Database Syst Rev. 2004;(3):CD000562. [abstract]
• Eating disorders, NICE (2004); Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders