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Bulimia

Definition

Bulimia is an illness in which a person binges on food or has regular episodes of significant overeating and feels a loss of control. The affected person then uses various methods -- such as vomiting or laxative abuse -- to prevent weight gain.

Many (but not all) people with bulimia also have anorexia nervosa.

Alternative Names

Bulimia nervosa; Binge-purge behavior; Eating disorder - bulimia

Causes, incidence, and risk factors

Many more women than men have bulimia, and the disorder is most common in adolescent girls and young women. The affected person is usually aware that her eating pattern is abnormal and may experience fear or guilt with the binge-purge episodes.

The exact cause of bulimia is unknown. Genetic, psychological, trauma, family, society, or cultural factors may play a role. Bulimia is likely due to more than one factor.

Symptoms

In bulimia, eating binges may occur as often as several times a day for many months.

People with bulimia typically eat large amounts of high-calorie foods, usually in secret. The person generally feels a loack of control over their eating during these episodes.

These binges cause a sense of self-disgust, which leads to what is called purging, in order to prevent gaining weight. Purging may include: making oneself vomit, excessive exercise, and use of laxatives, enemas, or diuretics (water pills). Purging often brings a sense of relief.

Body weight is often in the normal range, although people with bulimia often see themselves as being overweight. Because weight is often normal, this eating disorder may not be noticed by others.

Symptoms or behaviors that may be noticed include:

• Compulsive exercising
• Evidence of discarded packaging for laxatives, diet pills, emetics (drugs that induce vomiting), or diuretics (drugs that reduce fluids, also called water pills)
• Regularly going to the bathroom right after meals
• Suddenly eating large amounts of food or buying large quantities of food that disappear right away

Signs and tests

A dental exam may show dental cavities or gum infections (such as gingivitis). The enamel of the teeth may be eroded or pitted because of excessive exposure to the acid in vomit.

A physical examination may also reveal:

• Broken blood vessels in the eyes (from the strain of vomiting)
• Dry mouth
• Pouch-like appearance to the corners of the mouth due to swollen salivary glands
• Rashes and pimples
• Small cuts and calluses across the tops of the finger joints due to self-induced vomiting

A chem-20 test may show an electrolyte imbalance (such as hypokalemia) or dehydration.

Treatment

People with bulimia rarely need to be hospitalized, except under the following circumstances:

• Binge-purge cycles have led to anorexia
• Drugs are needed for withdrawal from purging
• Major depression is present

Most often, a stepped approach is taken for patients with bulimia. This treatment approach follows specific stages, depending on the severity of the bulimia, and the person's response to treatments:

• Support groups may be helpful for patients with mild conditions who do not have any health problems.
• Cognitive-behavioral therapy (CBT) and nutritional therapy is the preferred first treatment for bulimia that does not respond to support groups.
• Drugs used for bulimia are typically antidepressants known as selective serotonin-reuptake inhibitors (SSRIs). A combination of CBT and SSRIs is very effective if CBT is not effective alone.

Patients may drop out of programs if they have unrealistic expectations of being "cured" by therapy alone. Before a program begins, the following should be made clear:

• A number of therapies are likely to be tried until the patient succeeds in overcoming this difficult disorder.
• It is common for bulimia to return (relapse), and this is no cause for despair.
• The process is painful and requires hard work on the part of the patient and the patient's family.

Support Groups

Self-help groups like Overeaters Anonymous may help some people with bulimia. The American Anorexia/Bulimia Association is a source of information about this disorder.

See: Eating disorders - support group

Expectations (prognosis)

Bulimia is a chronic illness and many people continue to have some symptoms despite treatment. People with fewer medical complications of bulimia, and who are willing and able to engage in therapy, tend to have a better chance of recovery.

Complications

Bulimia can be dangerous and may lead to serious medical complications over time. For example, frequent vomiting puts stomach acid in the esophagus (the tube from the mouth to the stomach), which can permanently damage this area.

Possible complications include:

• Constipation
• Dehydration
• Dental cavities
• Electrolyte abnormalities
• Hemorrhoids
• Inflammation of the throat
• Pancreatitis
• Tears of the esophagus from excessive vomiting

Calling your health care provider

Call for an appointment with your health care provider if you (or your child) have symptoms of an eating disorder.

Prevention

Less social and cultural emphasis on physical perfection may eventually help reduce the frequency of this disorder.

References

American Psychiatric Association. Treatment of patients with eating disorders, 3rd ed. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54.

Hall MN, Friedman RJ 2nd, Leach L. Treatment of bulimia nervosa. Am Fam Physician. 2008 Jun 1;77(11):1588, 1592.

Schmidt U, Lee S, Beecham J, et al. A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders. Am J Psychiatry. 2007 Apr;164(4):591-8.