Bulimia nervosa, more commonly known as bulimia or The Poke and Choke, is an eating disorder. It is a psychological condition in which the subject engages in recurrent binge eating followed by an intentional purging. This purging is done in order to compensate for the excessive intake of the food and to prevent weight gain. Purging typically takes the form of vomiting; inappropriate use of laxatives, enemas, diuretics or other medication; excessive physical exercise, or fasting.



DSM-IV-TR criteria

The following five criteria should be met for a patient to be diagnosed with bulimia nervosa:[1]
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa.


History of bulimia nervosa

Bulimia nervosa was first described by Professor Gerald Russell in 1979 whilst he worked at the Royal Free Hospital, London. Bulimia nervosa has been recognized as an autonomous eating disorder by the American Psychiatric Association since 1980 [2]. The word “bulimia” is Latin, getting its roots from the Greek word “boulimia” which directly translates to mean “extreme hunger” [3].


Causes

Bulimia is often less about food, and more to do with deep psychological issues and profound feelings of lack of control. Binge/purge episodes can be severe, sometimes involving rapid and out of control feeding that can stop when the sufferers "are interrupted by another person" or when their stomach hurts from over-extension. This cycle may be repeated several times a week or, in serious cases, several times a day.[4] Sufferers can often "use the destructive eating pattern to gain control over their lives"[5].


Environmental factors

Rates of bulimia are much more prevalent in western civilizations, to the point that the disorder is almost non-existent in eastern cultures. As western civilization is becoming a more prominent figure in other cultures, through movies and television primarily, we are seeing a dramatic increase in the incidence of eating disorders in these cultures. The disorder is also much more prevalent in the Caucasian race, though as media influences have become stronger, the disorder is becoming a rising problem in the African American and Hispanic communities. Women are also 90% of patients who suffer from this disorder. Females involved in activities that put an extreme emphasis on thinness and body type (such as gymnastics, dance and cheerleading) are at the greatest risk for the development of eating disorders. [6]


Patterns of bulimic cycles

The frequency of bulimic cycles will vary from person to person. Some will suffer from an episode every few months while others who are more severely ill may binge and purge several times a day. Some people may vomit automatically after they have eaten any food. Others will eat socially but may be bulimic in private. Some people do not regard their illness as a problem, while others despise and fear the vicious and uncontrollable cycle they are in [7].


Subtypes of bulimia

The specific subtypes differ in the way the bulimic relieves themself of the binge.
Purging type
The purging type uses self-induced vomiting, laxatives, diuretics, enemas, or ipecac, as a means of rapidly extricating the contents from their body. This type is generally more commonly found, and can use one or more of the above methods on a [8].
Non-Purging Type
This type of bulimic is rarely found (only approximately 6%-8%), as it is a less effective means of ridding the body of such a large number of calories. This type of bulimic engages in excessive exercise or fasting following a binge in order to counteract the large amount of calories previously ingested. This is frequently observed in purging type bulimics as well, however this method is not their primary form of weight control following a binge [9].


Consequences of bulimia nervosa
Malnutrition
Dehydration
Electrolyte imbalance
Hyponatremia
Damaging of the voice
Vitamin and mineral deficiencies
Teeth erosion and cavities, gum disease
Sialadenosis (salivary gland swelling)
Potential for gastric rupture during periods of binging
Esophageal reflux
Irritation, inflammation, and possible rupture of the esophagus
Laxative dependence
Peptic ulcers and pancreatitis
Emetic toxicity due to ipecac abuse
Swelling of the face and cheeks, especially apparent in the lower eyelids due to the high pressure of blood in the face during vomiting.
Callused or bruised fingers
Dry or brittle skin, hair, and nails, or hair loss
Lanugo
Edema
Muscle atrophy
Decreased/increased bowel activity
Digestive problems that may be triggered, including Celiac, Crohn's Disease
Low blood pressure, hypotension
Orthostatic hypotension
High blood pressure, hypertension
Iron deficiency, anemia
Hormonal imbalances
Hyperactivity
Depression
Insomnia
Amenorrhea
Infertility
Polycystic Ovary Syndrome
High risk pregnancy, miscarriage, still-born babies
Diabetes
Elevated blood sugar or hyperglycemia
Ketoacidosis
Osteoporosis
Arthritis
Weakness and fatigue
Chronic Fatigue Syndrome
Cancer of the throat or voice box
Liver failure
Kidney infection and failure
Heart failure, heart arrhythmia, angina
Seizure
Paralysis
Potential death caused by heart attack or heart failure; lung collapse; internal bleeding, stroke, kidney failure, liver failure; pancreatitis, gastric rupture, perforated ulcer, depression and suicide.


Diagnosis

As mentioned earlier, all six of the criteria listed in the DSM are required for a classic diagnosis of bulimia nervosa. However, these symptoms are often difficult to spot, especially since, unlike anorexia nervosa, in order to be classified as bulimic the person must be of normal or higher weight. Likewise, the person is less likely to drop a significant amount of weight on a continual basis as does the anorectic, making the physical symptoms less noticeable, despite the fact that internal bodily functions are suffering. Because this disorder carries a great deal of shame, the bulimic will desperately try to hide their symptoms from family and friends. This disorder is more likely to span over a lifetime unnoticed, causing a great deal of isolation and stress for the suffering individual. Despite the frequent lack of obvious physical symptoms, bulimia nervosa has proven to be fatal, as malnutrition takes a serious toll on every organ in your body. If any of the symptoms above are noticed one should consult with a doctor or psychologist for further assistance [10].


Related psychological disorders

It is not uncommon that a patient with bulimia nervosa will also have some anxiety or mood disorder as well. Most commonly associated with bulimia is the incidence of anxiety, one study noted this in 75% of bulimic patients. Also prominent in bulimic patients are mood disorders, most commonly depression as well as substance abuse issues. However recent research suggest that depression is a consequence of the eating disorder itself, rather than the other way around. [11]. They are also more likely to attempt suicide, and engage in impulsive behaviors.


Differences between anorexia nervosa and bulimia nervosa

The main criteria differences involve weight, as an anorexic must technically be classified as underweight (defined as a BMI < 18.5, though to be diagnosed with anorexia, the patient generally must have a BMI of less than 17.5). Typically an anorexic is defined by the refusal to maintain a normal weight by self-starvation. Another criteria which must usually be met is amenorrhea, the loss of her menstrual cycle not caused by the normal cessation of menstruation during menopause. Generally the anorexic does not engage in regular binging and purging sessions. In the rare instant that this is observed, in that the patient binges and purges as well as fails to maintain a minimum weight they are classified as a purging anorexic, due to the underweight criteria being met. [12] Characteristically, those with bulimia nervosa feel more shame and out of control with their behaviors, as the anorexic meticulously controls her intake, a symptom that calms her anxiety around food as she feels she has control of it, naive to the notion that it, in fact, controls her. For this reason, the bulimic is more likely to admit to having a problem, as they do not feel they are in control of their behavior. The anorexic is more likely to believe they are in control of their eating and much less likely to admit to needing help, or that a problem even exists in the first place. Similarly, both anorexics and bulimics have an overpowering sense of self that is determined by their weight and their perceptions of it. They both place all their achievements and successes as the result of their body, and for this reason are often depressed as they feel they are consistently failing to achieve the perfect body. For the bulimic, because she cannot achieve the low weight she feels physically that she is a failure and this outlook infiltrates into all aspects of her life. The anorexic cannot see that she is truly underweight and is constantly working towards a goal that she will never meet. Because of this misconception she will never be thin enough, and therefore will be always working towards this unattainable goal. She too allows this failure at achieving the “perfect body” to define her self worth. As both the anorexic and bulimic never feel satisfaction in the more important part of their lives, depression often accompanies these disorders.[13]


Treatment of bulimia nervosa

Treatment is most effective when it is implemented early on in the development of the disorder. Unfortunately, since this disorder is often easier to hide and less physically noticeable, diagnosis and treatment often come when the disorder has already become a static part of the patient’s life. Historically, those with bulimia were often hospitalized to end the pattern and then released as soon as the symptoms had been relieved. However, this is now infrequently used, as this only addresses the surface of the problem, and soon after discharge the symptoms would often reappear as severe, if not worse, than when they had originally been.

There are several residential treatment centers across the country, which offer long term support, counseling, and symptom interruption. The most popular form of treatment for the disorder involves some form of therapy, oftentimes group psychotherapy or cognitive behavioral therapy. Anorexics and bulimics typically go through the same types of treatments and are members of these same treatment groups. This is because anorexia and bulimia often go hand in hand, and it is not unlikely that one has at some point participated in both. Some refer to this as "symptom swapping". These forms of therapy address both the underlying issues which cause the patient to engage in these behaviors, as well as the actual food symptoms as well. In combination with therapy, many psychiatrists will prescribe anti-depressants or anti-psychotics. Anti-depressants come in different forms, and the most promising drug to respond to bulimia has been Prozac. In a study done with 382 bulimia patients those who took between 20-60 mg of the drug reduced their symptoms from 45% to 67%, respectively. However, Prozac is the only drug that has been tested for bulimia, so it is quite possible that several others could be more effective. Often insurance companies will not pay for other drugs for the patient until he or she has tried Prozac, because it has some positive outcome results.

Anti-psychotics are also used, but in smaller doses than are used for treating schizophrenia. With an eating disorder, the patient perceives reality differently and has difficulty grasping what it is like to eat normally. Unfortunately, since this disorder has only recently been recognized by the DSM, long-term outcomes of people with the disorder are unknown. Current research indicates that up to 30% of patients rapidly relapse, while 40% are chronically symptomatic.

The rate in which the patient receives treatment is the most important factor affecting prognosis. Those who receive treatment early on for the disorder have the highest and most permanent recovery rates.


Mortality risk

Eating disorders have one of the highest death rates of all mental illnesses. The Eating Disorders Association (UK) estimates a 10% mortality rate. An 18% mortality rate has been suggested for Anorexia Nervosa.[1] In addition to the risk of suicide, “death can occur after severe binging in bulimia nervosa as well”.[14] For perspective, these death rates are higher than those of some forms of cancer.

Prevention

Currently, there is no known way to prevent the onset of bulimia nervosa. Less social and cultural emphasis on physical perfection might help, but it is difficult to make sweeping societal changes. And, as stressed earlier, the best method for preventing the progression of this disorder is early intervention by contacting your medical health professional and receiving psychotherapy. Adults have an immeasurable impact on their children, and focusing on developing a healthy lifestyle is key to raising healthy children in all aspects of life. Teaching children to adopt a healthy diet as a way of life and incorporating fun activities into their day will allow this to become second nature to them. Children should also be taught an emphasis on their internal characteristics and qualities rather than the external focus so much of society and the media tend to focus on. Action is the best method of teaching, and curtailing your own self-criticism and behavior will reflect substantially on your children’s impressions of themselves