Bulimia nervosa is defined as two or more episodes of
binge eating (rapid consumption of a large amount of food, up to 5,000
calories) every week for at least three months. The binges are
sometimes followed by vomiting or purging and may alternate with compulsive
exercise and fasting. The symptoms can develop at any age from early
adolescence to 40, but usually become clinically serious in late adolescence.
Bulimia is not as dangerous to health as anorexia, but it has many unpleasant
physical effects, including fatigue, weakness, constipation, fluid retention,
swollen salivary glands, erosion of dental enamel, sore throat from vomiting,
and scars on the hand from inducing vomiting. Overuse of laxatives can
cause stomach upset and other digestive troubles. Other dangers are
dehydration, loss of potassium, and tearing of the esophagus. These
eating disorders also occur in men and older women, but much less
frequently. Women with diabetes, who have a high rate of bulimia, often
lose weight after an eating binge by reducing their dose of insulin.
According to recent research, this practice damages eye tissue and raises the
risk of diabetic retinopathy, which can lead to blindness.
Many anorectic women also indulge in occasional eating binges, and half of
them make the transition to bulimia. About 40% of the most severely
bulimic patients have a history of anorexia. It is not clear whether
the combination of anorexia with bingeing and purging is more debilitating,
physically or emotionally, than anorexia alone. According to some
research, anorectic women who binge and purge are less stable emotionally and
more likely to commit suicide. But one recent study suggests that, on
the contrary, they are more likely to recover.
The exact cause of the disorder is unknown, but a variety of psychological,
social, cultural, familial and biochemical theories are being
investigated. Bulimia has been recognized for a much shorter time than
anorexia, and there is less research on its origins. One theory is that
bulimic women lack all the parental affection and involvement they need and
soothe them with food as compensation. The overeating subdues feelings
of which they are barely conscious, at the price of later shame and
self-hatred. One recent study found that bulimic women differed from
depressed and anxious women in several ways. They were more likely to
be overweight, to have overweight parents, and to have begun menstruating
early. They were also more likely to say that their parents had high
expectations for them but limited contact with them. The parents
themselves were not interviewed.
According to the American Journal of Psychiatry, surprisingly, the risk for
bulimia was not related to social class, income, education, occupation, the
occupation of parents, or even an outgoing or introverted personality.
A woman's childhood relationship with her mother, as she reported it, was not
associated with bulimia, but neglect by her father was. Women with
bulimia had lower self-esteem and more neurotic symptoms, and they were more
likely to say they were not in control of their lives. They also had a
slimmer ideal body image, and they dieted and exercised more. The risk
factors for narrowly and broadly defined bulimia were similar (Kendler,
Women with broadly defined bulimia had high rates of phobias, alcoholism,
anxiety disorders, anorexia nervosa, and panic attacks. Their lifetime
rate of major depression was also high (50 percent), but bulimia had no
special association with that common disorder. All other things being
equal, a woman with a history of major depression was 2.2 times more likely
to have suffered from bulimia as well. The corresponding odds ratio for
phobias was 2.4, for alcoholism 3.2, and for anorexia nervosa 8.2. In
most studies of patients treated for both bulimia and depression, bulimia is
found to precede depression, but in this group of largely untreated people
the depression had usually come first (Roth, 1996).
In some families of women with bulimia, the problem may be more serious than
rigidity, over protectiveness, or inadequate nurturing. Child sexual
abuse, an increasingly common explanation for psychiatric symptoms in women,
has naturally been proposed as a cause of eating disorders. The
connection has not been confirmed, and some recent studies raise serious
doubts about it. Women with bulimia do not report more sexual abuse
than an anxious and depressed woman in general.
The problem of bulimia is closely related to the problem of obesity, since
almost all bulimic women either are or think they are overweight.
According to a widely accepted theory, each person's body weight has a
biological set point that is strongly influenced by heredity and difficult to
change. Studies in several countries have found that mothers and their
biological daughters have a similar weight-height ratio, while the
correlation between adoptive parents and adoptive children is low.
According to the set point theory, metabolism during a diet shows to
counteract the effect of reduced intake until it settles at a lower level
consistent with the new weight. A person who continues the same diet
will eventually regain weight until the set point is reached.
Many individuals with bulimia do not seek help until they reach their
thirties or forties when their eating behavior is deeply ingrained and more
difficult to change.
Bulimia is often treated more successfully than anorexia, partly because
bulimic patients usually want to be treated. Most antidepressant drugs
relieve the symptoms, usually more quickly than they relieve
depression. Selective serotonin reuptake inhibitors (SSRIs) are
probably most useful, because they have relatively few side effects and tend
to cause weight loss rather than weight gain. In 1997, fluoxetine became
the first drug specifically approved by the Food and Drug Administration
(FDA) as a treatment for bulimia.
Roth, W.T., & Insel P.M. (1996). Core Concepts in
Health. Toronto: Mayfield.
Kendler, K.S. (1991). The genetic epidemiology of bulimia nervosa.
American Journal of Psychiatry, 148:1627-1637.
Mitchell, J.E. (1996). Bulimia Nervosa. West Virginia