Bulimia Nervosa

Clinical Presentation and Symptoms of Bulimia Nervosa

Bulimia nervosa involves frequent episodes of binge eating, almost always followed by purging and intense feelings of guilt or shame. Purging is a way for bulimics to exert control over their weight or shape. Body concerns unduly influence individual’s perception of themselves.

The characteristic features of Bulimia nervosa are

recurrent episodes of binge eating,
recurrent inappropriate behaviors (i.e., vomitting, taking laxatives) to compensate for binge eating in order to prevent weight gain, and
a self-evaluation that overemphasizes body shape and weight.

Bulimia nervosa can be a life-threatening disorder. Despite an apparently normal weight, those with the disorder share the psychopathological fear of fatness with those suffering from anorexia nervosaOpens in new window. However, an essential distinction in the clinical presentation is the presence of episodes of bingeing that are associated with different forms of purging and inappropriate compensatory behaviors, such as abuse of laxatives and diuretics (APA, 2013).

Binge eating episodes imply consumption of an abnormally large amount of food associated with the intense fear of being unable to stop or control the binge eating episodes. These episodes are combined with attempts to rid the body of the food by engaging in self-induced vomiting, excessive use of laxatives or diuretics, excessive exercise, or fasting (APA, 2013).

The binging and purging episodes are typically undertaken in utmost secrecy, and often result in rapid weight gains and losses. Moreover, an overwhelming feeling of guiltOpens in new window and shameOpens in new window follows each episode (APA, 2013).

DSM-5 Criteria

The DSM-5 diagnostic criteria states that binge eating (overeating) and trying to compensate for that overeating by vomiting, taking laxatives or diuretics, fasting, or exercising excessively (called purging) must be regularly occurring (i.e., at least once per week) and relatively persistent (i.e., over at least a 3-month period).

An episode of binge eating is defined as “eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances” (DSM-5, p. 345). For example, an individual might eat several quarts of ice cream or several large pizzas at one sitting.

The technical use of the term eating binge would ordinarily apply, however, to culturally sanctioned “overeating,” such as occurs at weddings or family Thanksgiving meals (although binge eating can occur at such events; see “A Visit to Food Hell,” later in this literature). An eating binge is typically associated with a feeling of a loss of control over eating, such that the individual cannot stop eating once started.

Some people report feeling “dissociated” (i.e., split off from conscious awareness of their behavior) when bingeing. Sometimes, people will report that they have completely given up trying to control their eating behavior. People will typically feel embarrassed about bingeing and will often eat in secrecy. Binges are often triggered by psychosocial stress, feelings of depression, or anxiety.

Compensatory behaviors in Bulimia Nervosa are called purge behaviors or purging (DSM-5, p. 346) and include self-induced vomiting (most common) and misuse of laxatives, diuretics, or enemas.

Some people with the disorder do not purge but rather compensate for overeating with fasting or excessive exercise (e.g., spending hours each day at the gym).

Individuals with Bulimia Nervosa are also very concerned about their body shape and weight as sources of self-esteem. In this respect, they are similar to people with Anorexia Nervosa; however, they do not have the low body weight caused by food restriction.

Bulimia Nervosa is not diagnosed when a person has Anorexia NervosaOpens in new window. People with Bulimia Nervosa are most commonly either normal weight or overweight. Serious medical complications can result from purging behaviors, including fluid and electrolyte imbalances, tears of the esophagus or rupture of the stomach (from vomiting), and cardiac arrhythmias (an alteration in the rhythm of the heartbeat in timing or force).

Bulimia Nervosa typically begins during late adolescence or early adulthood. The 12-month prevalence in young females is between 1% and 1.5%.

The disorder is 10 times more common in women than in men. It is most common in the United States among white women. The clinical course may be chronic or intermittent; the disorder may also diminish with time, with or without treatment, although treatment clearly leads to better outcomes.

People with Bulimia Nervosa have impaired social functioning in some cases (e.g., they may spend all of their “free time” bingeing and purging, instead of seeing friends or family, or they may avoid going out to restaurants because of a fear of engaging in an eating binge). People with this disorder are at risk for suicide.

Case study \| A Visit to Food Hell
Abby Thurmond, age 42, had not had a food binge for over 2 years when she flew from Miami to Chicago to attend the wedding of her friend’s daughter. Single, independent, and devoted to her work, Ms. Thurmond had just sold her first screenplay. She was pleased, but she was also experiencing the “postpartum” letdown that always occurred when she finished a major project. Ms. Thurmond knew from her 2 years in Overeaters Anonymous (OA; a self-help group program similar to Alcoholics Anonymous) that she needed to keep a safe distance from food, especially during emotionally hard times. Nevertheless, Ms. Thurmond spent the entire day of the wedding rehearsal party in the company of food. She stood in her friend’s kitchen for hours—cutting, chopping, sorting, arranging, and eventually picking at the food. That night, when the guests arrived, the flurry of activity made it easy for Ms. Thurmond to disappear—physically and emotionally—into a binge. She started with a plate of what would have been an “abstinent” meal (an OA concept for whatever is included on an individual’s meal plan): pasta salad, green salad, cold cuts, and a roll. Although the portions were generous, she wanted more. She spent the next 5 hours eating, at first trying to graze among the guests, but then, when shame set in, retreating to dark corners of the room to take frantic, stolen bites. Ms. Thurmond stuffed herself with crackers, cheeses, breads, chicken, turkey, pasta, and salads, but all that was a prelude to what she really wanted—sugar. She had been waiting for the guests to leave the dining room, where the desserts were. When they finally did, she cut herself two pieces of cake, then two more, and then ate directly from the serving tray, shoveling the food into her mouth. She reached for cookies, more cake, and cookies again. Heart racing, terrified of being discovered, she finally tore herself away and slipped out onto the terrace. At this point, in what she thought of as a “food trance,” Ms. Thurmond piled her plate with bread, onto which she smeared some unidentifiable spread. Although the food tasted like mud, she kept eating. Soon, other guests came out to the terrace, leaving Ms. Thurmond feeling she had to move again, which she did, stepping into the kitchen—and the light. When she glanced down at her plate, she was horrified; ants were crawling all over it. Instead of reflexively spitting out the food, Ms. Thurmond, overcome by shame, could only swallow. Then her eyes began to search the debris on her plate for uncontaminated morsels. Witnessing her own madness, Ms. Thurmond began to cry. She flung the plate into the trash and ran to her room. That event marked the beginning of a 6-monght relapse into binge eating—Ms. Thurmond’s worst experience with binge eating since the problem began 15 years earlier. During the relapse, she binged on sugar foods and refined carbohydrates, returned to cigarette smoking to control the binge eating, and once again was driven to “get rid” of the calories by incessant exercise after each binge, walking 4 – 5 hours at a time, dragging her bicycle up and down six flights of stairs, and biking miles after dark in a dangerous city park. Throughout the relapse, Ms. Thurmond went to therapy and to OA. However, the binge eating worsened, as did the accompanying isolation and depression, which kept her awake, often crying uncontrollably, until the early morning hours. Finally her therapist, a social worker, referred her to a psychiatrist, who prescribed an antidepressant medication that has been used to control binge eating, as well as a structured food plan that excluded refined sugars, breads, crackers, and similar carbohydrates. Within a few weeks, she was able to stop binge eating, come out of the depression, and resume her life. After 2 years of taking the medication, during which time she had no binges and gradually reintroduced breads and related carbohydrates to her diet, Ms. Thurmond was able to discontinue the antidepressant without depression or a return to binge eating. She continues to be active in OA.

Case study | A Visit to Food Hell

Abby Thurmond, age 42, had not had a food binge for over 2 years when she flew from Miami to Chicago to attend the wedding of her friend’s daughter. Single, independent, and devoted to her work, Ms. Thurmond had just sold her first screenplay. She was pleased, but she was also experiencing the “postpartum” letdown that always occurred when she finished a major project.

Ms. Thurmond knew from her 2 years in Overeaters Anonymous (OA; a self-help group program similar to Alcoholics Anonymous) that she needed to keep a safe distance from food, especially during emotionally hard times. Nevertheless, Ms. Thurmond spent the entire day of the wedding rehearsal party in the company of food. She stood in her friend’s kitchen for hours—cutting, chopping, sorting, arranging, and eventually picking at the food.

That night, when the guests arrived, the flurry of activity made it easy for Ms. Thurmond to disappear—physically and emotionally—into a binge. She started with a plate of what would have been an “abstinent” meal (an OA concept for whatever is included on an individual’s meal plan): pasta salad, green salad, cold cuts, and a roll. Although the portions were generous, she wanted more. She spent the next 5 hours eating, at first trying to graze among the guests, but then, when shame set in, retreating to dark corners of the room to take frantic, stolen bites.

Ms. Thurmond stuffed herself with crackers, cheeses, breads, chicken, turkey, pasta, and salads, but all that was a prelude to what she really wanted—sugar. She had been waiting for the guests to leave the dining room, where the desserts were. When they finally did, she cut herself two pieces of cake, then two more, and then ate directly from the serving tray, shoveling the food into her mouth. She reached for cookies, more cake, and cookies again. Heart racing, terrified of being discovered, she finally tore herself away and slipped out onto the terrace.

At this point, in what she thought of as a “food trance,” Ms. Thurmond piled her plate with bread, onto which she smeared some unidentifiable spread. Although the food tasted like mud, she kept eating. Soon, other guests came out to the terrace, leaving Ms. Thurmond feeling she had to move again, which she did, stepping into the kitchen—and the light. When she glanced down at her plate, she was horrified; ants were crawling all over it. Instead of reflexively spitting out the food, Ms. Thurmond, overcome by shame, could only swallow. Then her eyes began to search the debris on her plate for uncontaminated morsels. Witnessing her own madness, Ms. Thurmond began to cry. She flung the plate into the trash and ran to her room.

That event marked the beginning of a 6-monght relapse into binge eating—Ms. Thurmond’s worst experience with binge eating since the problem began 15 years earlier. During the relapse, she binged on sugar foods and refined carbohydrates, returned to cigarette smoking to control the binge eating, and once again was driven to “get rid” of the calories by incessant exercise after each binge, walking 4 – 5 hours at a time, dragging her bicycle up and down six flights of stairs, and biking miles after dark in a dangerous city park.

Throughout the relapse, Ms. Thurmond went to therapy and to OA. However, the binge eating worsened, as did the accompanying isolation and depression, which kept her awake, often crying uncontrollably, until the early morning hours. Finally her therapist, a social worker, referred her to a psychiatrist, who prescribed an antidepressant medication that has been used to control binge eating, as well as a structured food plan that excluded refined sugars, breads, crackers, and similar carbohydrates. Within a few weeks, she was able to stop binge eating, come out of the depression, and resume her life. After 2 years of taking the medication, during which time she had no binges and gradually reintroduced breads and related carbohydrates to her diet, Ms. Thurmond was able to discontinue the antidepressant without depression or a return to binge eating. She continues to be active in OA.

Discussion of “A Visit to Food Hell”

The term eating binge is often used by people to describe an occasion on which they ate more food than they should have. However, Ms. Thurmond’s description of the amount of food she consumed in her eating episode at the wedding rehearsal leaves little doubt that her episodes of binge eating, during which she has no control over how much she eats, represent a serious symptom.

When a clinician is diagnosing an individual with recurrent eating binges, the first question is whether the individual regularly compensates for the overeating by some drastic inappropriate behavior. If the answer is no, the diagnosis is probably Binge-Eating DisorderOpens in new window. If the answer is yes and the person’s self-evaluation is unduly influenced by body shape and weight (as usually occurs), the diagnosis is Bulimia Nervosa.

Most patients with Bulimia Nervosa compensate for the binge eating by some method of purging—either self-induced vomiting (most common) or the use of diuretics or laxatives. Ms. Thurmond’s case is an example of the relatively less common diagnosis of Bulimia Nervosa (DSM-5, p. 345), in which the patient uses excessive exercise (her method) or fasting (in other cases) instead of purging.

Case study II \| The Fat Man
Gregory James, a 43-year-old theatre manager, was evaluated at an eating disorders clinic in San Francisco. Although he had lost 58 pounds in the previous 5 months, dropping from 250 to 192 pounds on a 6’1” frame, he was still terrified of getting fat. Mr. James first began to diet 5 months earlier when his wife told him he was “a fat slob” and implied that she might be considering a divorce. This terrified him and started him on a strict dietary regimen: an omelet and bran for breakfast, coffee for lunch, and salad and shrimp or chicken for dinner. His original goal was to lose about 50 pounds. When dieting did not result in sufficiently rapid loss of weight, he started sticking his finger down his throat to induce vomiting after meals. Mr. Jamesis now “obsessed” with food. Before he goes to a restaurant, he worries about what he will order. He has done a study of what he eats in terms of what is easiest to purge, and he knows all the bathrooms in the areas he frequents. He cannot bear feeling full after eating and worries that his stomach is “fat.” Three or four times a week he is unable to resist the urge to “binge.” At those times a week he feels that his eating is out of control, and he may gobble down as much as three hamburgers, two orders of French fries, a pint of ice cream, and two packages of Oreo cookies. He always induces vomiting after a binge. He has never used laxatives, diuretics, or diet pills to lose weight. Mr. James is also preoccupied with becoming thin. He has progressively revised downward his original weight goal, first to 190 and then to 185 pounds. He has begun to exercise, walking at least an hour a day and, more recently, working out with weights several times a week. He believes that women look at him differently now: when he was heavy, they glanced at him casually, whereas now their response is “admiring.” Mr. James has always been somewhat heavy, turning to food in times of stress, but he never worried about his weight until his wife criticized his appearance. He can no longer enjoy any meals and feels he has lost control of this area of his life because he cannot stop dieting, even though his wife has told him he is now too thin. He therefore recently saw his internist who found no physical problems and referred him for psychiatric evaluation.

Case study II | The Fat Man

Gregory James, a 43-year-old theatre manager, was evaluated at an eating disorders clinic in San Francisco. Although he had lost 58 pounds in the previous 5 months, dropping from 250 to 192 pounds on a 6’1” frame, he was still terrified of getting fat.

Mr. James first began to diet 5 months earlier when his wife told him he was “a fat slob” and implied that she might be considering a divorce. This terrified him and started him on a strict dietary regimen: an omelet and bran for breakfast, coffee for lunch, and salad and shrimp or chicken for dinner. His original goal was to lose about 50 pounds. When dieting did not result in sufficiently rapid loss of weight, he started sticking his finger down his throat to induce vomiting after meals.

Mr. Jamesis now “obsessed” with food. Before he goes to a restaurant, he worries about what he will order. He has done a study of what he eats in terms of what is easiest to purge, and he knows all the bathrooms in the areas he frequents. He cannot bear feeling full after eating and worries that his stomach is “fat.” Three or four times a week he is unable to resist the urge to “binge.” At those times a week he feels that his eating is out of control, and he may gobble down as much as three hamburgers, two orders of French fries, a pint of ice cream, and two packages of Oreo cookies. He always induces vomiting after a binge. He has never used laxatives, diuretics, or diet pills to lose weight.

Mr. James is also preoccupied with becoming thin. He has progressively revised downward his original weight goal, first to 190 and then to 185 pounds. He has begun to exercise, walking at least an hour a day and, more recently, working out with weights several times a week. He believes that women look at him differently now: when he was heavy, they glanced at him casually, whereas now their response is “admiring.”

Mr. James has always been somewhat heavy, turning to food in times of stress, but he never worried about his weight until his wife criticized his appearance. He can no longer enjoy any meals and feels he has lost control of this area of his life because he cannot stop dieting, even though his wife has told him he is now too thin. He therefore recently saw his internist who found no physical problems and referred him for psychiatric evaluation.

Discussion of “The Fat Man”

Mr. James’ eating disorder began, as is often the case, with a reasonable attempt to lose some weight. He soon became preoccupied with losing weight and continued to view his body as “fat” even though others did not. His preoccupation with losing weight and distorted body image suggest Anorexia NervosaOpens in new window, but this diagnosis is not made because Mr. James has not let his weight go far below the normal minimum for his size.

Mr. James’ binges (recurrently eating a large amount of food with a sense of loss of control), his recurrent inappropriate compensatory behavior to avoid weight gain (in his case, by self-induced vomiting), and his overconcern with weight and shape indicate Bulimia Nervosa (DSM-5, p. 345).

Mr. James uses vomiting, the most common method for avoiding weight gain among individuals with Bulimia Nervosa. Less common methods for avoiding weight gain are misuse of laxatives or diuretics, fasting, and excessive exercise (see “A Visit to Food Hell,” the previous case study).

Mr. James’ case of Bulimia Nervosa is unusual in that he is a man (the disorder is 10 times more common among women) and onset of the disorder has been relatively later in life (onset is usually during adolescence or early adult life and is usually during adolescence or early adult life and is uncommon after age 40).

Treatment

Breaking the cycle of binge eating and compensatory behaviors is extremely difficult. The key to regaining control over your eating is to overcome dieting. This can be accomplished first by eating meals and snacks at regular intervals, not more than 4 to 5 hours apart.

Once eating patterns have been normalized, the next step is to stop restricting your diet. One way to do this is by gradually incorporating foods you fear and avoid into your diet. This forms the first step and is the basis for all other steps in this treatment program. There is good evidence supporting the effectiveness of this first step. In a study done at Stanford University, individuals with bulimia nervosa were treated with cognitive-behavioral therapy.

Of those who came closest to increasing their regularity of eating by consuming three meals and two snacks each day, 70% were no longer binge eating and purging at the end of treatment. On the other hand, of those who hardly changed their eating patterns, only % were no longer binge eating or purging at the end of treatment. These dramatic differences in outcome attest to the importance of this first step in treatment.

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Citation

Akkerman, K., Kaasik, K., Kiive, F., Nordquist, N., Oreland, L., & Harro, J. (2012, January). The impact of adverse life events and the serotonin transporter gene promoter polymorphism on the development of eating disorder symptoms. Journal of Psychiatric Research, 46(1), 38 – 43.
Alonso, D.R., Cortazar, A. E., Guillen, R.H., Fuentes, M.S., & Remesal, C. R. (2016, March). Food, body image, perfectionism. European Psychiatry, 33, S425.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Arlington, VA: The American Psychiatric Association.