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Bulimia nervosa, a psychiatric eating disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5)[1] is a mental health condition that manifests with repetitive behaviors that are intended to help the patient lose weight or avoid weight gain. This is accomplished by ridding the body of the partially digested food.[2]

It is considered the result of an abnormal and unhealthy view of one’s body and an intense desire to control one component of a person’s life when other external forces seem out of control.

As a mental health disorder, it can be caused by biological disturbances, environmental forces such as childhood trauma or extreme athletics, genetics, and self-esteem issues. Longstanding bulimia is a serious threat to health and has a 4% mortality. Early intervention is the key to long term success and sustained remission.

Signs of Bulimia

To reduce caloric absorption, people with bulimia will do the following:

• Self-induced vomiting with medications or digitally triggering the gag reflex;
• Laxative abuse;
• Excessive exercise;
• Diuretic abuse;
• Appetite suppressants;
• Strict dieting followed by binge eating;
• Not using appropriate insulin dosages;
• Ingesting metabolic hormones such as thyroid;

Symptoms

Bulimia nervosa may be characterized by the following symptoms: [3, 4, 5]

• Dizziness, lightheadedness, racing heart due to dehydration;
• Sore throat, abdominal pain, bloody vomit, difficulty swallowing, bloating, passing gas, constipation, and gastroesophageal reflux disease (GERD);[6]
• Lack of menstruation – amenorrhea – occurs in up to 50% of women with bulimia nervosa; irregular or light periods;[13, 14]
• Cardiac – Swelling, pulse changes;
• Enlarged stomach and increased risk of esophageal cancer;[7]
• Lung symptoms – coughing, aspiration pneumonitis (uncommon)- as stomach contents and acids enter the lung;
• Tooth decay and damage;
• Enlarged parotid glands (jawline);
• Hair loss, acne, dry skin;
• Low insulin, low thyroid hormone, and low glucose values;
• Low prolactin and disturbances in adrenal hormones.

Causes

The neurotransmitters serotonin, norepinephrine, and dopamine are associated with bulimia. Both bulimia and anorexia nervosa patients have been shown to have elevated levels of serotonin in their cerebrospinal fluid (CSF) which bathes the brain and spinal cord. Low levels of norepinephrine is more commonly associated with anorexia. Body image and binge eating are related to dopamine activity and bulimia.[15,16, 17]

Hormonal

A hormone that is secreted by the small intestine known as cholecystokinin  (CCK) is a hormone of digestion that breaks down fat and protein by stimulating the pancreas to release digestive enzymes. The overall result is the feeling of ‘fullness’ and diminished appetite. CCK and beta-endorphin levels are lower in people with bulimia.[18]

Genetics

Chromosomes 1, 3, and 10p are associated with bulimia with 10p also being linked to obesity, a risk factor for bulimia. As with any disease or disorder, genetics always play a role.

Developmental Factors

Childhood trauma, teasing, neglect, and psychological abuse may result in anxiety and bulimia. Separation from close caregivers is cited as another factor in bulimia.[19]

Psychological Factors

Poor coping skills, self-esteem, control issues, impulsivity, perfectionism, and distorted body image, make a person susceptible to dieting, eating disorders, and weight changes.

Sociocultural Factors

A complex interplay between mood disturbances, emotionality, boredom, alcohol, and substance abuse, may trigger episodes of bulimia.  Severe hunger or restricted food intake may trigger an excessive eating episode. There are concerns and unusual thoughts about physical appearance are seen in both anorexia nervosa and bulimia nervosa.

Family Issues

A family history of eating disorders, mood disorders, alcohol/drug abuse as well as chaotic, badly organized, lack of nurturance, neglectful, or hostile parents can be risk factors for developing an eating disorder. Teasing about weight is another factor.[12]

Diagnosis

Bulimia nervosa is a psychiatric eating disorder with five key characteristics as noted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5).[1]

1. Repetitive episodes of binge eating. Eating more than the average person in a 2-hour period, with a feeling of loss of control;
2. Repetitive and inappropriate behaviors to avoid weight gain, such as excessive exercise, fasting, laxative use, and diuretic use;
3. The behaviour occurs at least once a week for three months;
4. Body shape and actual weight affect self-image;
5. Not associated with episodes of anorexia nervosa.

Treatment Options

The majority of people with bulimia can be treated successfully in an outpatient setting. Those with significant medical complications, risk of suicide, or failed outpatient therapy should be hospitalized. The guidelines for level of care can be found in the APA Practice Guidelines for Eating Disorders

Generally, multiple professionals are needed to manage this condition, such as primary care practitioners., psychiatrist, nutritionists, and psychotherapists. The goals of therapy are to reduce or eliminate the eating/purging cycle, treat the complications, restore nutrition, educate about healthy eating habits, and help change their dysfunctional thoughts and feelings related to their body image and bulimia.

There are both medical and psychiatric complications of bulimia. There are higher rates of depression, anxiety, bipolar II, substance abuse, and a history of sexual abuse. The risk of suicide increases when depression, bulimia, and alcohol abuse coexist. [8,9]. Esophageal, stomach, and dental problems are common complications. Chronic ipecac can damage the heart. The mortality rate for bulimia is very close to those with anorexia.

Since this is a secretive disorder, a high index of suspicion should be maintained especially when someone leaves the dining area shortly after meals or someone who eats rapidly and excessively especially in a depressed or anxious individual who obsesses over their weight and body image.

Professionals can use the SCOFF questionnaire. It consists of 5 questions [10]:

1. Do you make yourself Sick because you feel uncomfortably full?
2. Do you worry you have lost Control over how much you eat?
3. Have you recently lost more than One stone (about 14 lbs or 6.35 kg) in a 3-month period?
4. Do you believe yourself to be fat when others say you are too thin?
5. Would you say that Food dominates your life?

Another screen for eating disorders is the Eating Disorder Screen for Primary Care (ESP) and consists of another set of 5 questions:[11]

1. Are you satisfied with your eating patterns?
2. Do you ever eat in secret?
3. Does your weight affect how you feel about yourself?
4. Have you ever had an eating disorder?

Conclusion

Mental health disorders such as bulimia and anorexia can be treated and cured under the following circumstances:

• If prompt identification is made;
• Less severe weight loss has occurred;
• No medical complications;
• Lack of a mood disorder.

The relapse rate is high and is usually triggered by emotional and social stress. A high index of suspicion for relapse can lower that rate with rapid intervention. Untreated, bulimia has a 4% mortality rate.

References

1.  American Psychiatric Association DSM-5. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013.

2. Langdon K. Bulimia Nervosa Guide: Symptoms, Warning Signs, Causes, & Treatments. Parenting Pod. 2018.

3. Mehler PS, Birmingham LC, Crow SJ, Jahraus JP. Medical Complications of Eating Disorders. Grilo CM, Mitchell JE. The Treatment of Eating Disorders: A Clinical Handbook. New York: The Guilford Press; 2010. 66.

4. Brown CA, Mehler PS. Medical complications of self-induced vomiting. Eat Disord. 2013. 21 (4):287-94.

5. Brown CA, Mehler PS. Successful "detoxing" from commonly utilized modes of purging in bulimia nervosa. Eat Disord. 2012. 20 (4):312-20.

6. Denholm M, Jankowski J. Gastroesophageal reflux disease and bulimia nervosa--a review of the literature. Dis Esophagus. 2011 Feb. 24 (2):79-85.

7. Dessureault S, Coppola D, Weitzner M, Powers P, Karl RC. Barrett's esophagus and squamous cell carcinoma in a patient with psychogenic vomiting. Int J Gastrointest Cancer. 2002. 32 (1):57-61.

8. Brauser D. Excessive Exercise Predicts Suicidal Behavior in Eating Disorders. Medscape Medical News. Apr 18 2013. Available at http://www.medscape.com/viewarticle/782742. Accessed: Apr 22 2013.

9. Smith AR, Fink EL, Anestis MD, Ribeiro JD, Gordon KH, Davis H, et al. Exercise caution: Over-exercise is associated with suicidality among individuals with disordered eating. Psychiatry Res. 2013 Apr 30. 206(2-3):246-55.

10. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999 Dec 4. 319(7223):1467-8.

11. Cotton MA, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. 2003 Jan. 18(1):53-6.

12. Keery H, Boutelle K, van den Berg P, Thompson JK. The impact of appearance-related teasing by family members. J Adolesc Health. 2005 Aug. 37(2):120-7.

13. Poyastro Pinheiro A, Thornton LM, Plotonicov KH, et al. Patterns of menstrual disturbance in eating disorders. Int J Eat Disord. 2007 Jul. 40(5):424-34.

14. Pinheiro, AP, Thornton, LH, Plotonicov, KH, et al. Patterns of Menstrual Disturbance in Eating Disorders. Intl J Eat Disord. 2007. 40:424-434.

15. Scherag,S, Hebebrand, J, Hinney, A. Eating disorders: the current status of molecular genetic research. Eur Child Adolesc Psychiatry. 2010. 19:211-226.

16. Kaye,W. Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior 94. (2008). 121-135.

17. Bailer, UF, Kaye, WH. A Review of Neuropeptides and Neuroendocrine Dysregulation in Anorexia Nervosa and Bulimia Nervosa. CNS and Neurological Disorders. 2003. 2:53-59.

18. Monteleone P, Maj M. Dysfunctions of leptin, ghrelin, BDNF and endocannabinoids in eating disorders: beyond the homeostatic control of food intake. Psychoneuroendocrinology. 2013 Mar. 38 (3):312-30.

19. Sadock BJ, and Sadock VA. Eating Disorders. Grebb, J.A., Pataki, C.S., and Sussman, N. Synopsis of Psychiatry. 10th Edition. Lippincott, Williams, & Wilkins; 2007. Chapter 23.