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Bulimia Nervosa

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Bulimia or binge-eating refers to episodes of excessive and uncontrolled food intake. Although bulimic symptoms can occur in both obesity and anorexia nervosa, they are also the central feature of the disorder known as bulimia nervosa.


For a definite, ICD 10 requires all of the following to be present.

 

  • A persistent preoccupation with eating, and an irresistible craving for food. The patient succumbs to episodes of overeating, in which large amounts of food are consumed in short periods of time.
  • Attempts are made to counteract the ‘fattening’ effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. Diabetic patients with bulimia may choose to neglect their insulin treatment.
  • There is a morbid dread of fatness and the patient sets herself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician.


In contract to anorexia nervosa, body weight is frequently normal or above normal, and many women continue to menstruate.


The syndrome of bulimia nervosa is mainly confined to women, the age of onset tending to be later than for anorexia nervosa, usually in late adolescence or early adulthood. Few studies on the prevalence of the disorder have been carried out, although a recent survey of French adolescents suggests a rate of 1.1% in females and 0.2% in males. The rate of case referral appears to be increasing, possibly because of media exposure and a growing awareness amongst the medical profession that abnormal eating behaviour can exist in those of normal body weight.


CLINICAL FEATURES


Characteristically, eating habits are grossly disturbed, and attempts at dietary restraint are disrupted by frequent binges, which are usually conducted in secret. Bingeing sometimes occurs in response to specific ‘cues’, such as an unpleasant event or a life crisis, or can be provoked by feelings of depression, loneliness or boredom.


Initially, binge-eating may relieve tension and be experienced as enjoyable, but as the amount of food consumed increases, it is rapidly followed by feelings of guilt, despair and loss of control. Carbohydrate-rich foods such as cakes, bread and biscuits are commonly chosen, and are frequently of a consistency which makes swallowing easy. Bulimics often binge at least two or three times a day (although it can be considerably more), and unless interrupted, each episode may continue until all the available food has been eaten or physical exhaustion occurs. Self-induced vomiting is extremely common and may be brought on in a number of ways. Some may regurgitate spontaneously by pressure on the abdomen, whilst others use fingers or specific objects (such as spoons) to stimulate the retching reflex. Most bulimics assume that self-induced vomiting will bring back all the food that has been eaten, whereas in reality up to two-thirds may remain in the stomach. Diuretic abuse, appetite suppressants, purging with laxatives, excessive exercise and dieting are additional methods employed to control weight.


Dichotomous thinking is a common feature of bulimia nervosa, the subject tending to view certain aspects of herself or her behaviour in uncompromisingly positive or negative terms. Consequently, she may see herself as either ‘fat or thin’, or her eating behaviour as ‘in or out of control’, which is often reflected by fluctuations in mood. Because bulimics are aware that their eating habits are abnormal, feelings of disgust and regret frequently occur during or after an episode of bingeing.


Preoccupations about food and eating often conflict with fears of obesity and a wish to be thin, or with a desire to reach and maintain an ‘ideal weight’. This commonly results in feelings of anxiety and tension, and a sense of depression or despair may ensue, sometimes leading to suicidal thoughts or acts. Other aspects of the bulimic’s life, in terms of relationships, sexual behaviour and drinking habits, may be equally chaotic. Some repeatedly indulge in antisocial or attention-seeking activities such as shoplifting, sexual promiscuity or self-mutilation, which may be related to alcohol or drug abuse.


Concentration is frequently impaired because of constant ruminations about body weight and size. Eating with others tends to be avoided and stringent efforts are often made to conceal their body shape from others and themselves. Body image is distorted by the sufferer not only feeling fat, but actually misperceiving and overestimating her body size.


Although weight usually remains within the normal range, physical complications can result in self-induced vomiting, diuretic or purgative abuse. Hypokalaemia may cause cardiac arrhythmias, tetany, paraesthesiae, seizures, muscle weakness and renal damage. Vomiting and the resultant acid regurgitation can produce erosion of dental enamel (perimolysis), painless enlargement of the salivary glands, hoarseness and oesophageal stricture, whilst purgative abuse may lead to development of steatorrhoea. Finger clubbing is sometimes evident, as well as calluses on the knuckles due to repeated abrasion against the teeth when inducing vomiting. Rarely, overeating can produce acute dilatation of the stomach.


AETIOLOGY


A past history of anorexia nervosa is found in nearly half of all bulimic patients. Many have a familial tendency towards obesity, so that their diet needs to be constantly controlled in order to attain the degree of desired slimness. However, it has also been demonstrated that such individuals rapidly abandon all restraint over their food intake once they believe they have eaten something with a high calorific content.


Patients suffering from bulimia nervosa are extremely sensitive to minor changes in shape and weight, to which they respond in an excessive manner. Poor self-image may lead to great value being placed on the need to be slim, so that uncompromising and rigid dietary regulations are imposed, accompanied by frequent checks of weight and size. Extreme dieting is known to induce bingeing.


Focussing on a specific body weight with special significance leads to the unyielding pursuit of an improbable target weight, thereby increasing the urge to restrict food intake. However, the belief that bingeing can be counteracted by extreme compensatory mechanisms may in turn enhance the amount of food eaten and the frequency of bulimic episodes. Remorse and shame following bingeing and vomiting can also lower self-esteem, thereby creating a vicious cycle.


Difficulties relating to work, studying or relationships may exist, and bulimia can emerge in the face of parental divorce or separation. Sometimes, concerns about sexual orientation are expressed, whilst many individuals describe s history of childhood sexual abuse.


MANAGEMENT


Assessment should include details of the patient’s eating habits, which can be recorded by means of a diary. The amount and type of food consumed are noted as well as how frequently eating occurs. The degree of enjoyment (or lack of it) that is experienced in association with eating should be identified, and the degree of control the individual experiences over food intake recorded (whether bingeing is spontaneous or planned). The diary can also be used to note factors which trigger bingeing (e.g. stress, low mood, a need for comfort, the availability of certain foods). Methods used to control weight should be ascertained whilst social, cultural and family problems also need to be identified.


Information from the diary can be used as part of a cognitive-behavioural approach to treatment. For example, if specific foods are identified as triggering binges, avoiding them might increase the amount of control the subject has over eating. Similarly, changing other behavioural patterns which are linked with bingeing (e.g. avoiding passing a particular shop where food for a binge is always purchased) may help to normalise dietary intake. Simple advice about eating regular small meals, the link between starvation and bingeing, not eating alone, can assist in eliminating bulimic symptoms. Information should also be given about the dangers of self-induced vomiting, purgation and excessive dietary restraint. Therapy may be provided either individually or in groups, recent research suggesting that the former might be slightly more effective.


In addition to offering support, psychotherapy helps to focus on events and feelings which act as stimuli to binge-eating. The subject is helped to anticipate future problems and deal with them appropriately and effectively.


Antidepressant drugs also have a role in the management of bulimia nervosa, as it has been demonstrated that dieting prior to bingeing causes a reduction in the level of activity of serotonergic neurones in the brain.

 

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