Bulimia nervosa

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2]

Bulimia is a Greek term that translates to “ravenous hunger”. Gerald Russell became the first person to publish a description of bulimia nervosa in 1979.

• Bulimia is a Greek term that translates to “ravenous hunger”.^[1][2]
• While Bulimia is considered an issue in modern day society, it was popular among the ancient Romans and Egyptians to either make more room to eat or because it was viewed as having health benefits.
• Gerald Russell became the first person to publish a description of bulimia nervosa in 1979. Bulimia nervosa then went on to make an appearance in the DSM-III a year later in 1980.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2]

Bulimia nervosa may be classified in to two types on the basis of purging behavior into purging and non-purging types.

Two subtypes of bulimia are distinguished by the way the bulimic relieves themselves of the binge.

Purging type is the more common type of bulimia, and involves any of self-induced vomiting, laxatives, diuretics, tapeworms, enemas, or ipecac, to rapidly extricate the contents from their body.^[1]

Non-purging type occurs in only approximately 6%-8% of bulimia cases, as it is a less effective means of ridding the body of such a large number of calories. It involves doing excessive exercise or fasting after a binge, to counteract the large amount of calories previously ingested. This often occurs in purging-type bulimics but is a secondary form of weight control.^[2]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

• Anorexia nervosa, binge-eating/purging type
• Binge-eating disorder
• Kleine-Levin syndrome
• Major depressive disorder, with atypical features
• Borderline personality disorder^[1]

The main criteria differences involve weight: an anorexic must have a body mass index of less than 17.5. Typically an anorexic is defined by the refusal to maintain a normal weight by self-starvation.

Another criterion which must usually be met is amenorrhea, the loss of a female’s menstrual cycle not caused by the normal cessation of menstruation during menopause for a period of three months. Generally the anorexic does not engage in regular binging and purging sessions. If binging and purging occurs but rarely, and the patient also fails to maintain a minimum weight, they are classified as a purging anorexic, due to the underweight criterion being met and cessation of menstruation. ^[2]

Characteristically, bulimics feel more shame and out of control with their behaviors, as the anorexic meticulously controls their intake, a symptom that calms their anxiety around food as s/he feels s/he has control of it, naïve to the notion that it, in fact, controls him/her. For this reason, the bulimic is more likely to admit to having a problem, as they do not feel they are in control of their behavior. The anorexic is more likely to believe they are in control of their eating and much less likely to admit that a problem exists.

Anorexics and bulimics have an overpowering sense of self determined by their body and their perceptions of it. They trace all their achievements and successes to it, and so are often depressed as they feel they are consistently failing to achieve the perfect body. Bulimics feel that they are a failure because s/he cannot achieve a low weight, and this outlook infiltrates into all aspects of their lives. Anorexics cannot see that they are underweight and constantly work towards a goal that they cannot meet. They too allow this failure to define their self worth. As both the anorexic and bulimic never feel satisfaction in the more important part of their lives, depression often accompanies these disorders.^[3]

Bulimia nervosa should also be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:^{[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]}

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2]

Very few studies regarding bulimia nervosa have been conducted on the general population, and thus, very little data is available. Bulimia nervosa is more prominent in females than in males. 0.1% to 1.4% of males are affected whereas 0.3% to 9.4% of females are affected.

Bulimia nervosa can occur in people of all ages, although it is more prevalent in younger populations.^[1][2]

Bulimia nervosa is more prominent in females than in males. 0.1% to 1.4% of males are affected whereas 0.3% to 9.4% of females are affected.^[1][2]

A recent study shows that African-American teenage girls are 50% more likely to deal with bulimia than Caucasian girls.^[1][2]

Bulimia nervosa is more common in developed countries as opposed to developing countries.^[1][2]

Bulimia nervosa is less common in developing countries as opposed to developed countries.^[1][2]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2]

The risk for Bulimia nervosa may be increased due to possible genetic predisposition, hormonal imbalances, and poor body image and self esteem.

The following conditions increases the risk of bulimia nervosa:

• Possible genetic predisposition^[1]
• Hormonal Imbalance (specifically serotonin)^[1]
• Sex hormone irregularities^[2]
• Poor body image and self-esteem as a result of “perfect” body types portrayed in the media^[3]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yashasvi Aryaputra[2]

Bulimia typically tends to start in late teens or early 20s. Bulimics go through cycles of over-eating and purging, that may be severe and devastating to the body. This cycle may be repeated several times a week or, in serious cases, several times a day. Bulimics may appear underweight, normal weight or overweight. Bulimia may cause several complications including malnutrition, dehydration, electrolyte imbalance, and vitamin and mineral deficiencies. The Eating Disorders Association of UK estimates it at 10%. An 18% mortality rate has been suggested for anorexia.

• Bulimia typically tends to start in late teens or early 20s.
• Bulimics go through cycles of over-eating and purging, that may be severe and devastating to the body.
• They sometimes involve rapid and out-of-control feeding that stops when the bulimic is interrupted by another person or when his/her stomach hurts from over-extension.
• This cycle may be repeated several times a week or, in serious cases, several times a day.^[1]

• Some bulimics eat secretly, others eat socially but are bulimic in private.
• They also differ in “how much” they purge. Some can vomit without gagging themselves after eating.
• Often when the urge hits, they go to great lengths to purge, as if an uncontrollable urge is making them do so.
• Medical evidence shows that the chemicals released when purging may make a person feel “high”. This can also lead to extreme dehydration and electrolyte imbalances.

• Some bulimics do not regard their cycles as a problem, while others despise and fear the vicious and uncontrollable cycle.^[2]
• Bulimics may appear underweight, normal weight or overweight.

Bulimia can cause following health problems:^[1]

• Malnutrition
• Dehydration
• Electrolyte imbalance, which can cause cardiac arrest or brain damage by stroke
• Hyponatremia
• Damaging of the voice
• Vitamin and mineral deficiencies
• Teeth erosion and cavities, gum disease
• Salivary gland swelling (sialadenosis)
• Potential for gastric rupture during periods of binging
• Esophageal reflux
• Irritation, inflammation, and possible rupture of the esophagus
• Laxative dependence
• Peptic ulcers and pancreatitis
• Emetic toxicity due to ipecac abuse
• Swelling of the face and cheeks, especially the lower eyelids, due to the high pressure of blood in the face during vomiting; for the same reason Purpura can occur, a rash caused by burst blood vessels.
• Callused or bruised fingers
• Dry or brittle skin, hair, and nails, or hair loss
• Lanugo
• Edema
• Muscle atrophy
• Decreased or increased bowel activity
• Digestive problems that may be triggered, including celiac, Crohn’s Disease
• Low blood pressure (hypotension)
  • Orthostatic hypotension
• High blood pressure (hypertension)
• Iron deficiency
• Anemia
• Hormonal imbalances
• Hyperactivity
• Depression
• Insomnia
• Amenorrhea
• Infertility
• High risk pregnancy, miscarriage, still-born babies
• Diabetes
• High blood sugar (hyperglycemia)
• Ketoacidosis
• Osteoporosis
• Arthritis
• Weakness and fatigue
• Chronic Fatigue Syndrome
• Cancer of the throat or voice box
• Liver failure
• Kidney infection and failure
• Heart failure, heart arrhythmia, angina
• Seizure
• Paralysis
• Death caused by heart attack or heart failure; lung collapse; internal bleeding, stroke, kidney failure, liver failure; pancreatitis, gastric rupture, perforated ulcer, depression and suicide.

• Eating disorders have one of the highest death rates of all mental illnesses.
• The Eating Disorders Association of UK estimates it at 10%. An 18% mortality rate has been suggested for anorexia.[3]
• These death rates are higher than those of some forms of cancer.