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Bulimia Nervosa - Causes, Symptoms And Treatment

Bulimia (buh-LEE -me-ah) nervosa, typically called bulimia, is a type of eating disorder. Someone with bulimia eats a lot of food in a short amount of time (called bingeing) and then tries to prevent weight gain by purging. Purging might be done in these ways:

  • making oneself throw up
  • taking laxatives, pills, or liquids that increase how fast food moves through your body and leads to a bowel movement (BM)

The essential features of bulimia nervosa include eating binges followed by feelings of guilt. humiliation,and sell-deprecation. These feelings cause the patient to engage in self-induced vomiting, abuse laxatives or diuretics, follow a strict diet, or fast to overcome the effects of the binges. Unless the patient spends an excessive amount of time bingeing and purging, bulimia nervosa is seldom incapacitating. However, electrolyte imbalances (metabolic alkalosis, hypochloremia, and hypokalemia) and dehydration can occur, increasing the risk for physical complications.

Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. It affects nine women for every man. Nearly 2% of adult women meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder. Eating disorders are most prevalent in affluent cultural groups and are essentially unknown in cultural groups where poverty and malnutrition are prevalent. In developing countries, almost no cases of eating disorders have been recognized.

Causes of bulimia nervosa

The cause of bulimia nervosa is unknown, but psychosocial factors may contribute to its development. These factors include family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity. cultural overemphasis on physical appearance, and parental obesity. Bulimia nervosa is commonly associated with depression. anxiety, phobias, and obsessive-compulsive disorder. all of which may interfere with recovery. Depression in a bulimic patient may lead to suicide attempts or a completed suicide.

Signs and symptoms of bulimia nervosa

The history of a patient with bulimia nervosa is characterized by episodes of binge eating that may occur up to several times a day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food is usually sweet, soft, and high in calories and carbohydrates.

the bulimic patient may appear thin and emaciated. Typically, however, although her weight frequently fluctuates. it usually stays within normal limits through the use of diuretics, laxatives, vomiting, and exercise. So, unlike the anorexic patient. the bulimic patient usually can hide her eating disorder.

Overt clues to this disorder include hyperactivity. peculiar eating habits or rituals, frequent weighing, and a distorted body image.

The patient may complain of abdominal and epigastric pain caused by acute gastric dilation. She may also have amenorrhea if she maintains a body weight too low to sustain a pregnancy. Repetitive vomiting may cause painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion. The patient may also exhibit calluses on the knuckles or abrasions and scars on the dorsum of the hand, caused by tooth injury during self-induced vomiting, although many bulimic persons induce vomiting chemically, such as with ipecac.

Others may perceive a bulimic patient as the "perfect" student, mother, or career woman; an adolescent may be distinguished for participation in competitive activities such as sports. However, the patient's psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships.

Diagnosis information

Diagnosis of bulimia begins with a history and physical examination. The primary care provider may order tests to check the person's health status, including:

  • blood tests such as a complete blood count
  • electrocardiography to check for heart problems
  • urinalysis to check for dehydration and infection
  • chest X-ray to check for rib fractures, heart problems, or lung infection
  • abdominal X-ray to look for digestive tract problems.

Additional diagnostic tools include the Beck Depression Inventory, which may identify coexisting depression, and laboratory tests to help determine the presence and severity of complications. Serum electrolyte studies may show elevated bicarbonate, decreased potassium, and decreased sodium levels.

Bulimia nervosa treatment

Treatment of bulimia nervosa may continue for several years. Interrelated physical and psychological symptoms must be treated simultaneously. Merely promoting weight gain isn't sufficient to guarantee long-term. A patient whose physical status is severely compromised by inadequate or chaotic eating patterns is difficult to engage in the psychotherapeutic process.

Psychotherapy concentrates on interrupting the binge-purge cycle and helping the patient regain control over her eating behavior. Inpatient or outpatient treatment includes behavior modification therapy, which may take place in highly structured psycho educational group meetings. Individual psychotherapy and family therapy, which address the eating disorder as a symptom of unresolved conflict, may help the patient understand the basis of her behavior and teach her self-control strategies. Antidepressant drugs, particularly selective serotonin re uptake inhibitors (SSRls), may be used as an adjunct to psychotherapy.

The patient may also benefit from participation in self-help groups such as Overeaters Anonymous or a drug rehabilitation program if she has a concurrent substance abuse problem.



Recognizing the bulimia patient isn't always easy. Unlike anorexic patients, bulimic patients don't deny that their eating habits are abnormal, but they commonly conceal their behavior out of shame. If you, suspect bulimia nervosa, be alert for the following features:

  • difficulty with impulse control
  • chronic depression
  • exaggerated sense of guilt
  • low tolerance for frustration
  • recurrent anxiety
  • feelings of alienation
  • self-consciousness
  • difficulty expressing feelings such as anger
  • impaired social or occupational adjustment.


Special considerations

Supervise the patient during mealtimes and for a specified period after meals (usually 1 hour). Set a time limit for each meal. Provide a pleasant, relaxed environment for eating.

  • Using behavior modification techniques, reward the patient for satisfactory weight gain.
  • Establish an eating contract with the patient, specifying the amount and type of food to be eaten at each meal.
  • Encourage her to recognize and express her feelings about her eating behavior. Maintain an accepting and nonjudgmental attitude, controlling your reactions to her behavior and feelings.
  • Encourage the patient to talk about stressful issues, such as achievement, independence, socialization, sexuality, family problems, and control.
  • Identify the patient's elimination patterns.
  • Assess her suicide potential. If she is suicidal, place her on suicide precautions and establish a suicide contract with her.
  • Refer the patient and her family to the American Anorexia/Bulimia Association and to Anorexia Nervosa and Related Eating Disorders for additional information and support.
  • Teach the patient how to keep a food journal to monitor treatment progress.
  • Outline the risks of laxative, emetic, and diuretic abuse for the patient.
  • Provide assertiveness training to help the patient gain control over her behavior and achieve a realistic and positive self-image.
  • If the patient is taking a prescribed tricyclic antidepressant, warn her to avoid consuming alcoholic beverages; exposing herself to sunlight, heat lamps, or tanning salons; and discontinuing the medication unless she has notified the physician.
  • SSRIs may take up to 4 to 8 weeks to establish their therapeutic effectiveness. They interfere with sexual functioning, and patients should be questioned about their sexual activity. Some SSRIs must be tapered rather than discontinued abruptly.

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