Bulimia Nervosa
   

Bulimia Nervosa
Also Listed As:  Eating Disorders, Bulimia
 
Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
Treatment Options
Treatment Plan
Drug Therapies
Complementary and Alternative Therapies
Prognosis/Possible Complications
Following Up
Supporting Research

Bulimia nervosa is an eating disorder characterized by periods of binge eating. In some cases, the person will compensate for this overeating by forcing vomiting; misusing laxatives, diuretics, or enemas; fasting; or excessive exercising. People with bulimia cannot control their eating and have a paralyzing fear of becoming fat. Bulimia is associated with depression and other psychiatric disorders and shares symptoms with anorexia nervosa, another major eating disorder. Because many individuals with bulimia maintain a normal or above-normal body weight, they are able to keep their condition a secret for years.


Signs and Symptoms

Bulimia is often accompanied by the following signs and symptoms:

  • Binge eating of high-carbohydrate foods, usually in secrecy
  • Loss of control over eating, with guilt and shame
  • Body weight that goes up and down
  • Constipation, diarrhea, nausea, gas, abdominal pain
  • Dehydration
  • Blood-tinged vomit
  • Irregular menstruation or cessation of menstrual periods
  • Eroded tooth enamel
  • Bad breath
  • Throat irritation and inflammation
  • Calluses on hands from forcing the body to vomit
  • Stealing, especially food
  • Depression
  • Substance abuse, especially alcohol

What Causes It?

There are several different theories about what is involved in the development of bulimia. Bulimia may have a hereditary component; in addition, some experts believe that a family environment with an overemphasis on achievement may be another contributing factor. The role of sexual abuse in the development of bulimia is controversial. Other psychological and environmental factors may be involved; these include mood disorders and substance abuse in families of people with bulimia. Individuals with bulimia may also experience depression, self-mutilation, substance abuse, and obsessive-compulsive behavior. Cultural pressures to appear slender contribute to the disorder, particularly among dancers and athletes.


Who's Most At Risk?

People with the following conditions or characteristics are at higher risk for developing bulimia:

  • White, middle-class women (primarily adolescents and college students)
  • People with a family history of mood disorders and substance abuse
  • Individuals with low self-esteem

What to Expect at Your Provider's Office

Often, people with bulimia are ashamed of their condition and do not seek help for many years, by which time their behaviors are deeply ingrained and harder to change. If you are experiencing symptoms associated with bulimia, you should see a healthcare provider as soon as possible. He or she will check for physical signs such as eroded tooth enamel and enlargement of the salivary glands, as well as signs of depression, possibly including marks from self-mutilation. Laboratory tests can reveal chemical changes caused by bingeing and purging, and psychological tests may point to obsessive-compulsive or antisocial behaviors.


Treatment Options
Treatment Plan

The most successful treatment is a combination of interpersonal therapy, family therapy, patient education, and medication.


Drug Therapies

Your provider may prescribe the following medications:

  • Fluoxetine, a selective serotonin reuptake inhibitor (SSRI) and currently the only FDA-approved drug for bulimia. Your doctor may also prescribe other antidepressants, such as other SSRIs, tricyclic antidepressants, or monoamine oxidase (MAO) inhibitors.
  • Potassium supplementation

Complementary and Alternative Therapies

Psychotherapy is a cornerstone of bulimia treatment. Using biofeedback may also help you to better manage stress. Other mind-body and stress-reduction techniques, such as yoga, tai chi, and meditation, may help you become more aware of your body and form a more positive body image. A 6-week clinical trial showed that guided imagery helped people with bulimia reduce bingeing and vomiting, feel more able to comfort themselves, and improve their feelings about their bodies and eating. More studies are needed to verify these findings and to determine if guided imagery has long-term benefits.


Nutrition

Nutrition therapy is as important as psychotherapy in treating bulimia. The goals of nutrition therapy are to stabilize your blood sugar levels, to make sure you are getting enough nutrients, and to restore your gastrointestinal health. In one study, 55 women with bulimia were assigned at random to either a nutritional management treatment group or a stress management treatment group. Nutritional management included information on the effects of bulimia, techniques to avoid binge eating, and advice about making meals and eating. Women in this group also had their eating diaries analyzed. Stress management included analysis of stressful situations; short-term stress management strategies, such as relaxation, self-encouragement, and self-distraction; and training in planning, problem solving, and communication. Women in the nutritional management group reduced their binge eating faster and were better able to avoid bingeing over the next year.

Some people with eating disorders are deficient in zinc. Variations in levels of zinc can affect taste, smell, appetite, and response to stress. Zinc deficiency may play a role in eating disorders and altered self-image. Taking zinc supplements may help with your treatment. In a recent study of 47 women with bulimia, zinc supplements seemed to reduce their obsession with weight and concern with body image. Your healthcare provider may also recommend a multivitamin with minerals to maintain levels of other important nutrients. B-complex vitamins may reduce stress and depression.

If you have trouble recognizing feelings of hunger, your provider may recommend eating small meals every 3 hours.


Herbs

While no scientific literature supports the use of herbs for bulimia, a trained naturopath or herbalist may recommend one or more of the following to alleviate stress, restore normal digestion and decrease anxiety:

  • Licorice root (Glycyrrhiza glabra)
  • Skullcap (Scutellaria lateriflora)
  • Oatstraw (Avena sativa)
  • Passionflower (Passiflora incarnata)
  • Lemon balm (Melissa officinalis)

Additional herbs may be considered to treat particular symptoms such as St. John's wort (Hypericum perforatum) for depression. St. John's wort must not be used with other antidepressants or with several other medications; see monograph entitled St. John's wort and check with your doctor for details. Taking any of the herbs mentioned for this condition should be done under the direction of an appropriately trained and certified specialist who will guide your individual care accordingly.


Homeopathy

No scientific literature supports the use of homeopathy for bulimia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.


Acupuncture

No scientific literature supports the use of acupuncture for bulimia. However, a trained acupuncturist may be able to recommend acupuncture treatments to support your overall treatment.


Massage

Therapeutic massage can be an effective part of a bulimia treatment plan. In one study, adolescent women with bulimia were assigned at random either to receive massage therapy for 5 weeks or to be in a control group (not receiving massage therapy). The 24 women receiving massage improved immediately, while the control group did not improve. Women in the massage group were less anxious and depressed right after their initial massages. They also had better scores on the Eating Disorder Inventory, which helps providers assess psychological and behavioral traits in eating disorders.


Prognosis/Possible Complications

Relapse is common in people with bulimia. Complications that can happen from repeated bingeing and purging include problems with the esophagus, stomach, heart, lungs, muscles, or pancreas. Suicidal individuals or those with severe symptoms may need to be hospitalized to prevent further complications. Pregnancy may be difficult emotionally for women with bulimia because of the changes in body shape that occur. Poor nutritional health of the mother may also have a negative impact on the unborn child. Women who have stopped menstruating because of bulimia will be unable to become pregnant.


Following Up

Since bulimia is usually a long-term disease, the person's weight, exercise habits, and physical and mental health need to be checked periodically by a healthcare provider.


Supporting Research

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Current concepts: eating disorders. N Engl J Med. 1999;340:1092-1098.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:107, 156-157, 160, 172, 180, 214-215.

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:160-161.

Esplen MJ, Garfinkel PE, Olmsted M, Gallop RM, Kennedy S. A randomized controlled trial of guided imagery in bulimia nervosa. Psychol Med. 1998;28(6):1347-1357.

Feldman M, ed. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia, Pa: W.B. Saunders; 1998.

Field T, Schanberg S, Kuhn C, et al. Bulimic adolescents benefit from massage therapy. Adolescence. 1998;33(131):555-563.

Foster D. Anorexia nervosa and bulimia nervosa. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:462-465.

Goroll AH, ed. Primary Care Medicine. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1995.

Hamilton EM, Gropper SA. The Biochemistry of Human Nutrition: A Desk Reference. New York, NY: West Publishing Company; 1987:278-279.

Kaplan HW, ed. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md: Williams & Wilkins; 1995.

Laessle RG, Beumont PJV, Butow P, et al. A comparison of nutritional management with stress management in the treatment of bulimia nervosa. Br J Psychiatry. 1991;159:250-261.

McClain CJ, Humphries LL, Hill KK, Nickl NJ. Gastrointestinal and nutritional aspects of eating disorders. J Am Coll Nutr. 1993;12(4):466-474.

Mooney J. Management of eating disorders. J Naturopathic Med. 1997;7(1):114-118.

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatr Int. 2000;42:76-81.

Rakel RE, ed. Conn's Current Therapy. 51st ed. Philadelphia, Pa: W.B. Saunders; 1999.

Schauss A, Costin C. Zinc as a nutrient in the treatment of eating disorders. Am J Nat Med. 1997;4(10):8-13.

Smith KA, Fairburn CG, Cowen PJ. Symptomatic relapse in bulimia nervosa following acute tryptophan depletion. Arch Gen Psychiatry. 1999;56:171-176.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Tarcher/Putnam; 1995.

Wilson JD, ed. Williams Textbook of Endrocrinology. 9th ed. Philadelphia, Pa: W.B. Saunders; 1998.


Review Date: March 2001
Reviewed By: Jacqueline A. Hart, MD, Department of Internal Medicine, Newton-Wellesley Hospital, Harvard University and Senior Medical Editor Integrative Medicine, Boston, MA.

Copyright © 2004 A.D.A.M., Inc

The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.

 
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