Bulimia Nervosa

• Feeling that you can't control your eating behavior
• Eating until the point of discomfort or pain
• Eating much more food in a binge episode than in a normal meal or snack
• Forcing yourself to vomit after eating
• Exercising excessively
• Misuse of laxatives, diuretics or enemas
• Being preoccupied with your body shape and weight
• Having a distorted, excessively negative body image
• Going to the bathroom after eating or during meals
• Abnormal bowel functioning
• Damaged teeth and gums
• Swollen salivary glands in the cheeks
• Sores in the throat and mouth
• Dehydration
• Irregular heartbeat
• Sores, scars or calluses on the knuckles or hands
• Menstrual irregularities or loss of menstruation (amenorrhea)
• Depression
• Anxiety

When you have bulimia, you may regularly vomit or exercise excessively after binge eating. Sometimes, however, people with bulimia feel a need to purge after eating only a small snack or a normal-size meal.

A binge is considered eating a larger amount of food than most people would eat under similar situations. For instance, when you have bulimia, you may eat an entire cake, rather than just a slice or two. And you may continue eating until you're painfully full.

Binges often occur in private. Once the binge episode ends, the purging begins. This may mean heading to the bathroom to vomit, hitting the treadmill for hours of exercise, or not eating for long periods of time (fasting). Because most people with bulimia are of normal weight or even slightly overweight, it may not be readily apparent to others that something is wrong.

Bulimia may be categorized in two ways:

• Purging bulimia. You regularly engage in self-induced vomiting or the misuse of laxatives, diuretics or enemas to compensate for binges.
• Nonpurging bulimia. You use other methods to rid yourself of calories and prevent weight gain, such as fasting or overexercising.

However, these behaviors often overlap, and the attempt to rid yourself of extra calories is usually referred to as purging, no matter what the method.

Causes

The exact cause of bulimia is unknown. As with other mental illnesses, there are many possible factors that could play a role in the development of eating disorders, such as genes, certain behaviors, psychological disorders, and family and societal influences:

• Biology. There may be genes that make some people more vulnerable to developing eating disorders. People with first-degree relatives — siblings or parents — with an eating disorder may be more likely to develop an eating disorder too, suggesting a possible genetic link. It's also possible that a deficiency in the brain chemical serotonin may play a role in the development of bulimia.
• Behavior. Certain behaviors, such as dieting or overexercising, can contribute to the development of bulimia. For example, dieting is a primary factor in triggering binge eating. In addition, dieting helps encourage rigid rules about food, which when broken can lead to loss of control and overeating.
• Emotional health. People with eating disorders may have psychological and emotional problems that contribute to the disorder. They may have low self-esteem, perfectionism, impulsive behavior, anger management difficulties, family conflicts and troubled relationships, for instance.
• Society. The modern Western cultural environment often cultivates and reinforces a desire for thinness. Success and worth are often equated with being thin in popular culture. Peer pressure and what people see in the media may fuel this desire to be thin, particularly among young women.

Risk factors

Certain situations and events might increase the risk of developing an eating disorder. These risk factors may include:

• Being female. Girls and women are more likely to have bulimia than boys and men are.
• Age. Bulimia often begins in late adolescence or early adulthood. Bulimia is more common in college students than in younger teens.
• Family history. Eating disorders, such as bulimia, are more likely to occur in people who have parents or siblings who've had an eating disorder.
• Dieting. People who lose weight are often reinforced by positive comments from others and by their changing appearance. This may cause some people to take dieting too far, leading to bulimia.
• Family influences. People who feel less secure in their families, whose parents and siblings may be overly critical, or whose families tease them about their appearance are at higher risk of bulimia and other eating disorders.
• Emotional disorders. People with depression, anxiety disorders and obsessive-compulsive disorder are more likely to have an eating disorder.
• Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of eating disorders, such as bulimia. Eating disorders are particularly common among ballerinas, gymnasts, runners and wrestlers. Coaches and parents may unwittingly contribute to eating disorders by encouraging young athletes to lose weight.

Complications

Bulimia may cause numerous serious and even life-threatening complications. Possible complications of bulimia include:

• Heart problems, such as an irregular heartbeat and heart failure
• Severe tooth decay
• In females, absence of a period
• Digestive problems, and possibly a dependence on laxatives to have bowel movements
• Drug and alcohol abuse
• Death

Diagnosis

When doctors suspect you have bulimia, they typically perform:

• A complete physical exam
• Blood and urine tests
• A psychological evaluation, including a discussion of your eating habits and attitude toward food

Additionally, your doctor may also request an X-ray to check for broken bones, pneumonia or heart problems, and an electrocardiogram may be done to look for heart irregularities.

Diagnostic criteria for bulimia

These tests help doctors determine if you meet the criteria for bulimia or if you may have another eating disorder, such as anorexia or binge-eating disorder. To be diagnosed with bulimia, you must meet these criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association.

DSM criteria for bulimia include:

• Repeated episodes of binge eating, including eating an abnormally large amount of food and feeling that you lack control over your eating.
• Repeated efforts to counteract your bingeing, such as self-induced vomiting, excessive exercise, fasting, or misuse of laxatives, diuretics, enemas or other medications.
• These behaviors generally occur at least twice a week for at least three months.
• Your feelings of self-worth are overly influenced by body shape and weight.
• You don't have anorexia nervosa, another eating disorder characterized by extremely restrictive eating behaviors.

Some people may not meet all of these criteria but still have an eating disorder. Don't try to diagnose yourself — get professional help if you have any eating disorder symptoms.

Treatments and drugs

When you have bulimia, you may need several types of treatment, although combining psychotherapy with antidepressants may be the most effective for overcoming the disorder. Treatment is generally done using a team approach that includes you, your family, your primary care doctor or other medical provider, as well as mental health providers and dietitians experienced in treating eating disorders. You may have a case manager to coordinate all of your care.

Here's a look at bulimia treatment options and considerations:

Psychotherapy

Psychotherapy is a general term for a way of treating bulimia by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as therapy, talk therapy, counseling or psychosocial therapy.

A type of talk therapy called cognitive behavioral therapy may help people with bulimia. This type of therapy is based on the idea that your own thoughts — not other people or situations — determine how you behave. Cognitive behavioral therapy helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. An important negative belief that cognitive behavioral therapy addresses is the idea that restrictive eating can help you stay thin, when in fact, the reality is that fasting can often trigger binge eating.

Family-based therapy can also be an effective treatment for children and adolescents with eating disorders. This type of therapy begins with the assumption that the person with the eating disorder is no longer capable of making sound decisions regarding his or her health and needs help from the family. An important part of family-based therapy is that the family is involved in making sure that healthy-eating patterns are followed and helping the person restore weight. This type of therapy can help resolve family conflicts and encourage support from concerned family members.

Medications

Antidepressant medications may help reduce the symptoms of bulimia. The only antidepressant specifically approved to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI). However, doctors can also prescribe other antidepressants or medications to treat your bulimia. Antidepressants or psychiatric medications can also help treat accompanying mental disorders, such as depression or anxiety.

Weight restoration and nutrition education

If you're underweight due to bulimia, the first goal of treatment will be to start getting you back to a normal weight. No matter what your weight, dietitians and other health care providers can give you information about a healthy diet and help design an eating plan that can help you achieve a healthy weight and instill normal-eating habits. If you have binge-eating disorder, you may benefit from medically supervised weight-loss programs.

Hospitalization

Bulimia can usually be treated outside of the hospital. But if you have a severe form of bulimia and serious health complications, you may need treatment in a hospital. When needed, hospitalization may be on a medical or psychiatric ward. Specialized eating disorder clinics may offer intensive inpatient treatment, or eating disorder programs may offer day treatment, rather than full inpatient hospitalization.

Treatment challenges in bulimia

Like other eating disorders, bulimia can be difficult to overcome or manage. Although the majority of people with bulimia do recover, some find that bulimia symptoms don't go away entirely. Periods of bingeing and purging may come and go through the years, depending on your life circumstances. In times of high stress, for instance, you may return to familiar, if unhealthy, eating behavior. If you find yourself back in the binge-purge cycle, "booster" sessions with your health care providers may help you weather the crisis before your eating disorder spirals out of control again. Learning positive ways to cope, creating healthy relationships and managing stress can help prevent a relapse.

Lifestyle remedies

Although you can't treat bulimia on your own, you can do some things for yourself that will build on your treatment plan. In addition to professional treatment, follow these self-care tips for bulimia:

• Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
• Get the right nutrition. Talk to your doctor about appropriate vitamin and mineral supplements. If you aren't eating well or you're frequently purging, it's likely your body isn't getting all of the nutrients it needs.
• Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
• Stay in touch. Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart and that nurturing, caring friendships are healthy for you.
• Be kind to yourself. Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
• Be cautious with exercise. Talk to your health care providers about what kind of exercise, if any, is appropriate for you, especially if you exercise excessively as a way to burn off post-binge calories.

Alternative medicine

Usually, when people turn to alternative medicine it's to improve their health, but for people with eating disorders this isn't always the case. Alternative medicine treatments have both negative and positive consequences when it comes to eating disorders.

The bad

There are numerous dietary supplement and herbal products designed to suppress the appetite or aid in weight loss, and these products may be abused by people with eating disorders. These products can have potentially dangerous interactions with other medications, such as laxatives or diuretics, that are commonly used by people with eating disorders. Additionally, weight-loss supplements or herbs can have serious side effects on their own, such as irregular heartbeats, tremors, hallucinations, insomnia, nausea, dizziness and nervousness. Discuss the potential risks of using dietary supplements or herbs for weight loss with your doctor.

The good

Although yoga has not yet been well studied as a treatment for people with eating disorders, some research has found that yoga may be beneficial as an additional treatment. It may help people with eating disorders by increasing a sense of well-being and promoting relaxation.

Coping and support

You may find it difficult to cope with bulimia when you're hit with mixed messages by the media, culture, and perhaps your own friends or peers. You may even have heard people joke that they wish they could throw up after overeating.

So how do you cope with a disease that can be deadly when you're also getting messages that being thin is a sign of success?

• Remind yourself what a healthy weight is for your body, especially at times when you see images that may trigger your desire to binge and purge.
• Resist the urge to diet or skip meals. Dieting actually triggers binge eating and makes it difficult to cope with stress.
• Don't visit Web sites that advocate or glorify eating disorders. These sites can encourage you to maintain dangerous habits and can trigger relapses.
• Identify troublesome situations that are likely to trigger thoughts or behavior that may contribute to your bulimia so that you can develop a plan of action to deal with them. Also have a plan in place to cope with the emotional distress of setbacks.
• Look for positive role models who can help boost your self-esteem, even if they're not easy to find. Remind yourself that the ultrathin models or actors showcased in popular magazines often don't represent healthy, fit bodies.
• Find pleasurable activities to engage in. This can help distract you from thoughts about bingeing and purging and also help you develop healthy hobbies.
• Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement — just as you would do for a loved one.

Coping advice for parents

If you're the parent of someone with bulimia nervosa, you may blame yourself for your child's eating disorder. But, eating disorders have many causes and it's better not to waste time trying to figure out why the eating disorder occurred. Instead, focus on how you can help your child now.

Here are some suggestions for supporting your child:

• Ask your child what you can do to help. Would it be helpful if you made sure that certain trigger foods aren't in the house? Or, would your teen like it if you planned family activities after meals to reduce the temptation to purge?
• Listen. Allow your child to express his or her feelings.
• Schedule regular family mealtimes. Regular eating is an important component for reducing binge eating.
• Let your adolescent know any concerns you have, but try to do so without placing blame.

It's also important to remember that eating disorders affect the whole family and that you need to take care of yourself too. If you feel that you aren't coping well with your teen's illness, you might benefit from professional counseling. Or, ask your child's doctor if he or she knows of any support groups in your area for parents of children with eating disorders.

Prevention

While there's no sure way to prevent bulimia, there may be ways to help. For instance, pediatricians may be in a good position to identify early indicators of an eating disorder and help prevent its development. During routine well-child checks or medical appointments, they can ask children questions about their eating habits and satisfaction with their appearance. In addition, parents can cultivate and reinforce a healthy body image in their children no matter what their size or shape. Be sure not to tease or joke about a child's size, shape or appearance.

If you notice a family member or friend with low self-esteem, severe dieting, disordered eating behaviors and dissatisfaction with appearance, consider talking to her or him about these issues. Although you may not be able to prevent an eating disorder from developing, your encouragement can steer someone toward healthier behavior or professional treatment before the situation worsens.

References:

http://www.timberlineknolls.com/eating-disorder/bulimia/signs-effects/

http://www.bodywhys.ie/aboutED/bulimia/

http://www.helpguide.org/articles/eating-disorders/bulimia-nervosa.htm

https://www.nationaleatingdisorders.org/bulimia-nervosa

https://en.wikipedia.org/wiki/Bulimia_nervosa