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 illnesses that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two illnesses. For example, in anorexia nervosa you are very underweight, whereas in bulimia nervosa you are most likely to be normal weight or above.

What are the symptoms of bulimia nervosa?

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

• Bingeing means that you have repeated bouts of eating large quantities of foods or liquids. For example, you may eat a whole large tub of ice cream or two packets of biscuits, but you will not necessarily be 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 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 or other drugs such as amphetamines.

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, but 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.

Physical problems
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.

• Teeth problems caused by the acid from the stomach rotting away the enamel with repeated vomiting.
• Body chemical imbalances caused by repeated vomiting or excess use of laxatives. For example, a low potassium level may develop which may cause tiredness, weakness, abnormal heart rhythms, kidney damage, and convulsions. Low calcium levels can lead to tetany (muscle spasms).
• Bowel problems may occur if you use a lot of laxatives. They can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation.
• Menstrual periods may become irregular.
• Swollen saliva glands which can make your face look swollen.

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 fashion which portrays the idea that it is fashionable to be slim. The images of slim models may not be a problem to many people. However, some people become depressed if they do not conform to these 'ideals' which may lead them to develop bulimia or anorexia.

There may be some genetic factor to develop bulimia which is triggered by bad or traumatic life experiences. For example, some people with bulimia tell of a childhood where there were frequent family problems with arguments and criticism at home. One study showed that half of all people with a serious eating disorder had evidence of PTSD (post traumatic stress disorder). Another study showed that 4 in 10 women with bulimia had suffered sexual abuse.

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 certain 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 other unknown factors, may lead to a low level of serotonin.

Who gets bulimia nervosa?

Mainly women aged 16-40, but it most commonly starts around the age of 19. It sometimes develops in men and children. Bulimia is becoming more common. During the 1980's the number of cases increased threefold and continues to increase. Studies suggest that about 8 in 100 women have problems with bulimia at some stage in their life. About 5 in 100 female college students have bulimia.

As mentioned, 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 treatments for bulimia nervosa?

Many people who see their GP with bulimia will be referred to a specialist mental health team. Members of the team may include psychiatrists, psychologists, nurses, dieticians and other professionals. However, it is not always possible to be seen quickly. Depending on the severity of the illness, your GP may be able to treat you.

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

• Psychological ('talking') treatments. CBT (cognitive behavioural therapy) is the most commonly used 'talking' 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 how to deal with emotional issues. This treatment requires regular sessions over 4-6 months. Studies have shown that it may work better when combined with medication. 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.
• Medication may be advised in addition to CBT. The most commonly used medicines are SSRI's (selective serotonin reuptake inhibitors). These are often used for depression but were found to also work well in some people with bulimia. The doses are up to three times higher than those used for depression. They may take 6-8 weeks to work. So do persevere if you are prescribed one.
• Treatment of any physical or teeth problems that may occur. 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 Eating Disorders Association listed 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 illness that is difficult to cure fully 'once and for all'. Many people improve, but bad spells (relapses) may recur from time to time in some cases. Also, some people who are considered 'cured' remain with eating patterns that are not fully 'normal' throughout their lives.

Studies suggest that 10 years after a diagnosis of bulimia about 5 in 10 are well, about 2 in 10 still have bulimia, and about 3 in 10 are somewhere in the middle. About 1 in 20 develop anorexia nervosa. It is very unusual to die from bulimia (in contrast to anorexia nervosa where about 1 in 20 people with anorexia die from the consequences of the illness).

Pregnancy sometimes helps. One study showed that after childbirth a third of women who had bulimia no longer had it.

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.

Eating Disorders Association
103 Prince of Wales Road, Norwich, NR1 1DW
Tel: 0870 770 3256   Web: www.edauk.com
Offers information and support.

© EMIS and PIP 2004   Updated: July 2004   Review Date: August 2005   CHIQ Accredited   PRODIGY Validated