Overview
Bulimia Nervosa is an eating disorder characterized by recurrent episodes of binge-eating accompanied by purging behavior in order to compensate for it. Symptoms of Bulimia Nervosa can lead to serious social, functional, and psychological distress, and the disorder is associated with significant medical and psychiatric comorbidities.
Bulimia Nervosa is associated with a female preponderance, and the onset is typically in adolescence. Genetic and neurobiological factors as well as temperamental, environmental and sociocultural factors make up the aetiology of the disorder.
Treatment modalities for Bulimia Nervosa include psychotherapeutic and pharmacological approaches.
Signs and Symptoms
The signs and symptoms of Bulimia Nervosa may include:
- Recurrently binge-eating
- Compensating for excessive food intake through inappropriate behaviors such as self-induced vomiting or use of laxatives
- Engaging in excessive exercise that interferes with daily activities or is carried out at inappropriate times
- Being preoccupied with own body shape
- Fear of gaining weight
- Desire to lose weight
- Being overweight
- Fluctuating weight
- Selecting low-calorie foods between binging episodes
- Menstrual irregularity
- Gastrointestinal problems
Social Anxiety Disorder (Social Phobia) can have mental & physical implications.
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Risk Factors
Eating Disorders, including Bulimia Nervosa, are largely associated with a female predominance in prevalence. Some studies have shown a reduction in the gap between sex distribution of eating disorders in more recent years, illustrating a shift in demographic data. The development of the disorder commonly begins in adolescence, and is associated with puberty and the period of transition between adolescence and adulthood.
Genetic and environmental factors are both considered to precipitate the occurrence of the disorder. Bulimia Nervosa is also associated with certain neurobiological abnormalities, including a heightened pain threshold, abnormal brain activation in taste processing regions, and disturbances in the insula.
Individuals suffering from Bulimia Nervosa also experience problems in emotional regulation and impulsivity. They may face difficulties in using appropriate strategies to control emotional intensity, be unable to remain goal-oriented in times of stress, and have problems accepting certain states of emotionality. They may also experience elevated levels of impulsivity. Perinatal complications may also play a part in the development of the disorder.
Predisposing factors may also include childhood experiences of abuse and neglect, including sexual abuse, as well as parenting styles. External sociocultural factors may also lead to the idealization of a โthinโ body, which can further increase the risk of an eating disorder. Temperamental factors such as lower self-esteem, preoccupation with weight, neuroticism, and anxiousness can also elevate the possibility of the occurrence of Bulimia Nervosa. Dieting can precede the development of the disorder, and has also been linked to the precipitation of serotonin abnormalities.
A high likelihood of other psychiatric comorbidities exists when an individual is diagnosed with Bulimia Nervosa, and many individuals may experience multiple comorbidities. Depressive symptoms seen in depressive and bipolar disorders, mood disturbances, anxiety, alcohol or stimulant use, and personality disorders are commonly seen as comorbidities. There is also a heightened suicide risk involved.
Diagnosis
A thorough clinical assessment is required to make a diagnosis of Bulimia Nervosa. Annual check-ups or compulsory health examinations are an ideal time to screen for symptoms and consult with individuals. The first priority in screening for any eating disorder is to identify any medical complication resulting from the disorder and provide emergency treatment if required.
Laboratory tests and physical examinations are also carried out. The mouth of the individual may be physically examined in order to look for certain markers resulting from persistent self-induced vomiting, such as the loss of dental enamel, chipped teeth, enlarged salivary glands, and scars or calluses on the roof of the mouth.
The SCOFF questionnaire is one of the screening instruments devised in order to assess the likelihood of an eating disorder in adults. Recently, the use of Virtual Reality in the assessment of Bulimia Nervosa has also shown some efficacy, making use of VR scenarios in order to measure behavioral and cognitive aspects associated with certain scenarios.
The DSM-5 contains the following criteria for the diagnosis of Bulimia Nervosa:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specifications of the diagnosis of Bulimia Nervosa are made on the basis of state of remission, as well as the degree of severity of the disorder.
Treatment
Due to significant comorbidities associated with the disorder, as well as the increased mortality rate it involves, treatment for Bulimia Nervosa is imperative. Management modalities for the disorder may comprise of both psychotherapeutic and psychopharmacologic treatment methods.
Psychotherapy is necessary in treating Bulimia Nervosa, as individuals may face significant psychological distress. Psychotherapeutic means aim to utilize various strategies in order to influence behavioral adjustment. The first line of psychotherapeutic treatment is usually either Family Therapy, Cognitive Behavioral Therapy, or a combination of the both, which can consist of guided self-care, the use of workbooks, sessions with close friends or family, and behavioral experiments. The role of family members in helping the individual restore appropriate eating habits is highlighted. Cognitive Behavioral Therapy adapted for adolescents (CBT-A), supportive psychotherapy, and psychodynamic therapy are other approaches that may be implemented.
Psychopharmacology for Bulimia Nervosa is mainly based on the use of antidepressants such as fluoxetine. The use of medication in treatment of the disorder is done in conjunction with the implementation of psychotherapeutic modalities.ย
Differential Diagnosis
1. Anorexia nervosa, binge-eating/purging type: Individuals whose binge-eating behavior occurs only during episodes of anorexia nervosa should not be given the diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa but no longer meet the full criteria for anorexia nervosa, binge-eating/purging type, a diagnosis of bulimia nerves should be given provided the criteria for bulimia nervosa are met for minimum 3 months.
2. Binge-eating disorder: Some individuals binge eat but do not practice any compensatory behaviors. In these cases, the diagnosis of binge-eating disorder should be considered.
3. Kleine-Levin syndrome: In some neurological or other medical conditions, such as Kleine-Levin syndrome, there is disturbed eating behavior, but the psychological features of bulimia nervosa (concern with body shape and weight) are not present.
4. Major depressive disorder, with typical features: Overeating is common in major depressive disorder. But individuals with this major depressive disorder do not practice compensatory behaviors and do not express excessive concern with body shape and weight. If criteria for both disorders are met, both diagnoses should be given.
5. Borderline personality disorder: Binge-eating behavior is included in the impulsive behavior of borderline personality disorder. If the criteria for both borderline personality disorder and bulimia nervosa are met, both diagnoses should be given.
Comorbidity
Bulimia nervosa is found to be highly comorbid. Each bulimic individual reports at least one other mental disorder. comorbid with bipolar disorder, anxiety disorders and depressive disorders. Some disorders occur before the onset of bulimia nervosa while some occur during it. A prevalence of substance use is common as an attempt to reduce weight. Bulimic individuals are also prone to personality disorders, most likely borderline personality disorder.
Specialist
Owing to the possibility of significant medical comorbidities, it is ideal that a multidisciplinary team be involved in the assessment and treatment of Bulimia Nervosa. The initial symptoms may be recognized by general practitioners, who may go on to involve a clinician trained in appropriate screening and treatment modalities with adequate expertise in managing eating disorders.
