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Bulimia nervosa

Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight.[9][2] This activity aims to expel the body of calories eaten from the binging phase of the process.[9] Binge eating refers to eating a large amount of food in a short amount of time.[2] Purging refers to the attempts to get rid of the food consumed.[2] This may be done by vomiting or taking laxatives.[2]

"Binge and purge" redirects here. For the Lunachicks album, see Binge & Purge. For the 2002 film, see Binge & Purge (film). For Metallica album, see Live Shit: Binge & Purge.

Bulimia nervosa

Bulimia

Eating a large amount of food in a short amount of time followed by vomiting or the use of laxatives, often normal weight[1][2]

Genetic and environmental factors[2][4]

Based on person's medical history[5]

Half recover over 10 years with treatment[4]

3.6 million (2015)[8]

Other efforts to lose weight may include the use of diuretics, stimulants, water fasting, or excessive exercise.[2][4] Most people with bulimia are at normal weight.[1] The forcing of vomiting may result in thickened skin on the knuckles, breakdown of the teeth, and effects on metabolic rate and caloric intake which cause thyroid dysfunction.[2][10] Bulimia is frequently associated with other mental disorders such as depression, anxiety, borderline personality disorder,[11] bipolar disorder,[12] and problems with drugs or alcohol.[2] There is also a higher risk of suicide and self-harm.[3]


Bulimia is more common among those who have a close relative with the condition.[2] The percentage risk that is estimated to be due to genetics is between 30% and 80%.[4] Other risk factors for the disease include psychological stress, cultural pressure to attain a certain body type, poor self-esteem, and obesity.[2][4] Living in a culture that commercializes or glamorizes dieting and having parental figures who fixate on weight are also risks.[4]


Diagnosis is based on a person's medical history;[5] however, this is difficult, as people are usually secretive about their binge eating and purging habits.[4] Further, the diagnosis of anorexia nervosa takes precedence over that of bulimia.[4] Other similar disorders include binge eating disorder, Kleine–Levin syndrome, and borderline personality disorder.[5]

Chronic after eating, secondary to vomiting[15]

gastric reflux

and hypokalemia due to renal potassium loss in the presence of alkalosis and frequent vomiting[16]

Dehydration

can lead to abnormal heart rhythms, cardiac arrest, and even death

Electrolyte imbalance

or inflammation of the esophagus

Esophagitis

Mallory-Weiss tears

a rupture in the esophageal wall due to vomiting

Boerhaave syndrome

Oral , in which repetitive insertion of fingers or other objects causes lacerations to the lining of the mouth or throat

trauma

: calluses on knuckles and back of hands due to repeated trauma from incisors[17][18]

Russell's sign

or severe dental erosion of tooth enamel[19]

Perimolysis

Swollen (for example, in the neck, under the jawline)[19][20]

salivary glands

or delayed gastric emptying

Gastroparesis

or diarrhea

Constipation

or palpitations

Tachycardia

Hypotension

Peptic ulcers

Infertility

Constant weight fluctuations are common

Elevated , cholesterol, and amylase levels may occur

blood sugar

may occur after vomiting

Hypoglycemia

Causes[edit]

Biological[edit]

As with anorexia nervosa, there is evidence of genetic predispositions contributing to the onset of this eating disorder.[36] Abnormal levels of many hormones, notably serotonin, have been shown to be responsible for some disordered eating behaviors. Brain-derived neurotrophic factor (BDNF) is under investigation as a possible mechanism.[37][38]


There is evidence that sex hormones may influence appetite and eating in women and the onset of bulimia nervosa. Studies have shown that women with hyperandrogenism and polycystic ovary syndrome have a dysregulation of appetite, along with carbohydrates and fats. This dysregulation of appetite is also seen in women with bulimia nervosa. In addition, gene knockout studies in mice have shown that mice that have the gene encoding estrogen receptors have decreased fertility due to ovarian dysfunction and dysregulation of androgen receptors. In humans, there is evidence that there is an association between polymorphisms in the ERβ (estrogen receptor β) and bulimia, suggesting there is a correlation between sex hormones and bulimia nervosa.[39]


Bulimia has been compared to drug addiction, though the empirical support for this characterization is limited.[40] However, people with bulimia nervosa may share dopamine D2 receptor-related vulnerabilities with those with substance use disorders.[41]


Dieting, a common behaviour in bulimics, is associated with lower plasma tryptophan levels.[42] Decreased tryptophan levels in the brain, and thus the synthesis of serotonin, such as via acute tryptophan depletion, increases bulimic urges in currently and formerly bulimic individuals within hours.[43][44]


Abnormal blood levels of peptides important for the regulation of appetite and energy balance are observed in individuals with bulimia nervosa, but it remains unknown if this is a state or trait.[45]


In recent years, evolutionary psychiatry as an emerging scientific discipline has been studying mental disorders from an evolutionary perspective. If eating disorders, Bulimia nervosa in particular, have evolutionary functions or if they are new modern "lifestyle" problems is still debated.[46][47][48]

Social[edit]

Media portrayals of an 'ideal' body shape are widely considered to be a contributing factor to bulimia.[23] In a 1991 study by Weltzin, Hsu, Pollicle, and Kaye, it was stated that 19% of bulimics undereat, 37% of bulimics eat an average or normal amount of food, and 44% of bulimics overeat.[49] A survey of 15- to 18-year-old high school girls in Nadroga, Fiji, found the self-reported incidence of purging rose from 0% in 1995 (a few weeks after the introduction of television in the province) to 11.3% in 1998.[50] In addition, the suicide rate among people with bulimia nervosa is 7.5 times higher than in the general population.[51]


When attempting to decipher the origin of bulimia nervosa in a cognitive context, Christopher Fairburn et al.'s cognitive-behavioral model is often considered the golden standard.[52] Fairburn et al.'s model discusses the process in which an individual falls into the binge-purge cycle and thus develops bulimia. Fairburn et al. argue that extreme concern with weight and shape coupled with low self-esteem will result in strict, rigid, and inflexible dietary rules. Accordingly, this would lead to unrealistically restricted eating, which may consequently induce an eventual "slip" where the individual commits a minor infraction of the strict and inflexible dietary rules. Moreover, the cognitive distortion due to dichotomous thinking leads the individual to binge. The binge subsequently should trigger a perceived loss of control, promoting the individual to purge in hope of counteracting the binge. However, Fairburn et al. assert the cycle repeats itself, and thus consider the binge-purge cycle to be self-perpetuating.[53]


In contrast, Byrne and Mclean's findings differed slightly from Fairburn et al.'s cognitive-behavioral model of bulimia nervosa in that the drive for thinness was the major cause of purging as a way of controlling weight. In turn, Byrne and Mclean argued that this makes the individual vulnerable to binging, indicating that it is not a binge-purge cycle but rather a purge-binge cycle in that purging comes before bingeing. Similarly, Fairburn et al.'s cognitive-behavioral model of bulimia nervosa is not necessarily applicable to every individual and is certainly reductionist. Every one differs from another, and taking such a complex behavior like bulimia and applying the same one theory to everyone would certainly be invalid. In addition, the cognitive-behavioral model of bulimia nervosa is very culturally bound in that it may not be necessarily applicable to cultures outside of Western society. To evaluate, Fairburn et al..'s model and more generally the cognitive explanation of bulimia nervosa is more descriptive than explanatory, as it does not necessarily explain how bulimia arises. Furthermore, it is difficult to ascertain cause and effect, because it may be that distorted eating leads to distorted cognition rather than vice versa.[54][55]


A considerable amount of literature has identified a correlation between sexual abuse and the development of bulimia nervosa. The reported incident rate of unwanted sexual contact is higher among those with bulimia nervosa than anorexia nervosa.[56]


When exploring the etiology of bulimia through a socio-cultural perspective, the "thin ideal internalization" is significantly responsible. The thin-ideal internalization is the extent to which individuals adapt to the societal ideals of attractiveness. Studies have shown that young women that read fashion magazines tend to have more bulimic symptoms than those women who do not. This further demonstrates the impact of media on the likelihood of developing the disorder.[57] Individuals first accept and "buy into" the ideals, and then attempt to transform themselves in order to reflect the societal ideals of attractiveness. J. Kevin Thompson and Eric Stice claim that family, peers, and most evidently media reinforce the thin ideal, which may lead to an individual accepting and "buying into" the thin ideal. In turn, Thompson and Stice assert that if the thin ideal is accepted, one could begin to feel uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal set out by society. Thus, people feeling uncomfortable with their bodies may result in body dissatisfaction and may develop a certain drive for thinness. Consequently, body dissatisfaction coupled with a drive for thinness is thought to promote dieting and negative effects, which could eventually lead to bulimic symptoms such as purging or bingeing. Binges lead to self-disgust which causes purging to prevent weight gain.[58]


A study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is Thompson's and Stice's research. Their study aimed to investigate how and to what degree media affects the thin ideal internalization. Thompson and Stice used randomized experiments (more specifically programs) dedicated to teaching young women how to be more critical when it comes to media, to reduce thin-ideal internalization. The results showed that by creating more awareness of the media's control of the societal ideal of attractiveness, the thin ideal internalization significantly dropped. In other words, less thin ideal images portrayed by the media resulted in less thin-ideal internalization. Therefore, Thompson and Stice concluded that media greatly affected the thin ideal internalization.[59] Papies showed that it is not the thin ideal itself, but rather the self-association with other persons of a certain weight that decide how someone with bulimia nervosa feels. People that associate themselves with thin models get in a positive attitude when they see thin models and people that associate with overweight get in a negative attitude when they see thin models. Moreover, it can be taught to associate with thinner people.[60]

History[edit]

Etymology[edit]

The term bulimia comes from Greek βουλιμία boulīmia, "ravenous hunger", a compound of βοῦς bous, "ox" and λιμός, līmos, "hunger".[108] Literally, the scientific name of the disorder, bulimia nervosa, translates to "nervous ravenous hunger".

Before the 20th century[edit]

Although diagnostic criteria for bulimia nervosa did not appear until 1979, evidence suggests that binging and purging were popular in certain ancient cultures. The first documented account of behavior resembling bulimia nervosa was recorded in Xenophon's Anabasis around 370 B.C, in which Greek soldiers purged themselves in the mountains of Asia Minor. It is unclear whether this purging was preceded by binging.[109] In ancient Egypt, physicians recommended purging once a month for three days to preserve health.[110] This practice stemmed from the belief that human diseases were caused by the food itself. In ancient Rome, elite society members would vomit to "make room" in their stomachs for more food at all-day banquets.[110] Emperors Claudius and Vitellius both were gluttonous and obese, and they often resorted to habitual purging.[110]


Historical records also suggest that some saints who developed anorexia (as a result of a life of asceticism) may also have displayed bulimic behaviors.[110] Saint Mary Magdalen de Pazzi (1566–1607) and Saint Veronica Giuliani (1660–1727) were both observed binge eating—giving in, as they believed, to the temptations of the devil.[110] Saint Catherine of Siena (1347–1380) is known to have supplemented her strict abstinence from food by purging as reparation for her sins. Catherine died from starvation at age thirty-three.[110]


While the psychological disorder "bulimia nervosa" is relatively new, the word "bulimia", signifying overeating, has been present for centuries.[110] The Babylon Talmud referenced practices of "bulimia", yet scholars believe that this simply referred to overeating without the purging or the psychological implications bulimia nervosa.[110] In fact, a search for evidence of bulimia nervosa from the 17th to late 19th century revealed that only a quarter of the overeating cases they examined actually vomited after the binges. There was no evidence of deliberate vomiting or an attempt to control weight.[110]

20th century[edit]

Globally, bulimia was estimated to affect 3.6 million people in 2015.[8] About 1% of young women have bulimia at a given point in time and about 2% to 3% of women have the condition at some point in their lives.[3] The condition is less common in the developing world.[4] Bulimia is about nine times more likely to occur in women than men.[5] Among women, rates are highest in young adults.[5] Bulimia was named and first described by the British psychiatrist Gerald Russell in 1979.[111][112]


At the turn of the century, bulimia (overeating) was described as a clinical symptom, but rarely in the context of weight control.[113] Purging, however, was seen in anorexic patients and attributed to gastric pain rather than another method of weight control.[113]


In 1930, admissions of anorexia nervosa patients to the Mayo Clinic from 1917 to 1929 were compiled. Fifty-five to sixty-five percent of these patients were reported to be voluntarily vomiting to relieve weight anxiety.[113] Records show that purging for weight control continued throughout the mid-1900s. Several case studies from this era reveal patients with the modern description of bulimia nervosa.[113] In 1939, Rahman and Richardson reported that out of their six anorexic patients, one had periods of overeating, and another practiced self-induced vomiting.[113] Wulff, in 1932, treated "Patient D", who would have periods of intense cravings for food and overeat for weeks, which often resulted in frequent vomiting.[110] Patient D, who grew up with a tyrannical father, was repulsed by her weight and would fast for a few days, rapidly losing weight. Ellen West, a patient described by Ludwig Binswanger in 1958, was teased by friends for being fat and excessively took thyroid pills to lose weight, later using laxatives and vomiting.[110] She reportedly consumed dozens of oranges and several pounds of tomatoes each day, yet would skip meals. After being admitted to a psychiatric facility for depression, Ellen ate ravenously yet lost weight, presumably due to self-induced vomiting.[110] However, while these patients may have met modern criteria for bulimia nervosa, they cannot technically be diagnosed with the disorder, as it had not yet appeared in the Diagnostic and Statistical Manual of Mental Disorders at the time of their treatment.[110]


An explanation for the increased instances of bulimic symptoms may be due to the 20th century's new ideals of thinness.[113] The shame of being fat emerged in the 1940s when teasing remarks about weight became more common. The 1950s, however, truly introduced the trend of aspiration for thinness.[113]


In 1979, Gerald Russell first published a description of bulimia nervosa, in which he studied patients with a "morbid fear of becoming fat" who overate and purged afterward.[111] He specified treatment options and indicated the seriousness of the disease, which can be accompanied by depression and suicide.[111] In 1980, bulimia nervosa first appeared in the DSM-III.[111]


After its appearance in the DSM-III, there was a sudden rise in the documented incidents of bulimia nervosa.[110] In the early 1980s, incidents of the disorder rose to about 40 in every 100,000 people.[110] This decreased to about 27 in every 100,000 people at the end of the 1980s/early 1990s.[110] However, bulimia nervosa's prevalence was still much higher than anorexia nervosa's, which at the time occurred in about 14 people per 100,000.[110]


In 1991, Kendler et al. documented the cumulative risk for bulimia nervosa for those born before 1950, from 1950 to 1959, and after 1959.[114] The risk for those born after 1959 is much higher than those in either of the other cohorts.[114]

Anorectic Behavior Observation Scale

Eating recovery

Evolutionary psychiatry

Binge eating disorder

List of people with bulimia nervosa