When you eat excessively and then try to purge the food through various means, you’re suffering from bulimia.

BULIMIA nervosa is an eating disorder that is characterized by cycles of eating large amounts of food (binge eating) followed by the sufferer taking measures to get rid of it (purging) by stimulating vomiting, use of laxatives, or excessive exercising.

The cause of eating disorders is unknown. However, it is believed to be due to a complex interaction between biological, family, psychological, and social factors.

The causative factors include:

·Family history of parents or siblings with an eating disorder suggests a biological factor.

·Psychological factors like poor self-esteem, perfectionism, disturbed relationships and family conflicts may be contributing factors.

·Social factors like media focus on body shapes and peer pressure may be contributing factors in teenage girls.

The factors that increase the risk of an eating disorder include:

·Teenage girls and young women.

·Teenage girls whose parents and siblings place an undue emphasis on physical appearance and body weight.

·People suffering from depression, anxiety disorders and obsessive-compulsive disorder.

·Stressful situations like discontinuation of relationship(s).

·Occupations like athletes, dancers, models, ballerinas, gymnasts.

Bulimia nervosa and anorexia nervosa are similar in that there is an inaccurate perception of body weight, size or shape and/or marked over-concern about body weight, size or shape.

However, there are differences. Bulimia nervosa is characterised by inappropriate weight reducing behaviour (vomiting, laxative or diuretic abuse, excessive exercise, fasting) at least twice a week and large uncontrolled binge eating at least twice a week.

Anorexia nervosa is characterised by voluntary maintenance of unhealthy low weight (less than 85% of expected), cessation of menstrual periods for at least three cycles (amenorrhoea), and an intense fear of weight gain or becoming fat.

Eating disorders usually affect young females, with a female to male ratio of 10-20 to one. The average prevalence of bulimia nervosa and anorexia nervosa in young females in developed countries is 1% and 0.3% respectively. Although there is no local data, it is believed the prevalence in Malaysia is not very far off these rates.

Characteristics of bulimia

The clinical features of bulimia nervosa include repeated episodes of binge eating and purging. During the binge eating, the sufferer experiences loss of control and eats beyond comfortable fullness.

The binge eating is followed by purging of the food consumed, typically with self-induced vomiting, laxative abuse, medicines that increase passage of urine (diuretics) and use or abuse of medicines used for dieting. There are frequent attempts at dieting, which include over-exercising.

It is common for sufferers to have abdominal fullness and constipation because of delayed gastric emptying, laxative abuse, and decreased intestinal motility.

The vomiting may be associated with electrolyte disturbances from the loss of the body’s sodium, potassium and chloride, swelling of the parotid salivary gland behind the cheek, erosion of the enamel of the teeth, sores in the mouth and throat, and callous swellings on the dorsum of the fingers consequent to the abutment of the teeth in self-induced vomiting.

There may be bruises on the chest or abdomen that are shaped like the contours of the toilet bowl.

Laxative abuse can lead to electrolyte disturbances and changes in the body’s chemistry. Electrolyte and/or pH disturbances lead to low blood pressure, heart rate abnormalities, electrocardiogram (ECG) changes, muscle weakness, fits and kidney failure.

Serious and even fatal consequences may result.

Like anorexia nervosa, there is an association of bulimia nervosa with other mental health conditions like depression, anxiety disorders, obsessive compulsive disorders, personality disorders, and addictive disorders. The presence of these mental health disorders in a young woman would raise suspicions of an eating disorder.

Bulimia nervosa sufferers are more likely to have problems controlling their impulses, leading to self-harm, sexual promiscuity, and shoplifting.

Managing the condition

There are three main components in the management of bulimia nervosa, just like in anorexia nervosa, ie assessment, correction of physical abnormalities, and restoration of weight; development of regular meals and normal eating patterns, and cessation of purging; and psychological therapy and prevention of relapse.

Prior to commencement of treatment, an assessment of the patient’s medical and social needs, risks and severity of the condition will have to be made.

An assessment of the patient’s physical, psychosocial and familial functioning is the basis of good treatment. Most patients with bulimia nervosa will consult a doctor willingly. This makes engagement and the development of rapport easier. This is unlike the person with anorexia nervosa, who is often a defiant adolescent and denies that there is anything wrong with them.

Significant abnormalities have to be corrected first. As the weight is not usually critically low in bulimia nervosa, unlike anorexia nervosa, emphasis is placed on regular meals and the elimination of bingeing and purging. The onset of self-induced vomiting often heralds an increase in the frequency and amount of binge eating.

Depending on the severity of the condition, treatment can be done as an outpatient (this is most common), or in a day unit, or as in inpatient in hospital.

The psychological treatment involves cognitive analytic therapy (CAT), cognitive behavioural therapy (CBT), interpersonal therapy (IPT), focal psychodynamic therapy (FPT), and family therapy (FT).

CAT is based on the theory that bulimia is due to unhealthy patterns of behaviour and thinking, which the patient has developed in the past, usually in childhood. It involves reformulation, ie looking for past events that may explain why the unhealthy patterns developed, recognition of how these patterns are contributing towards the bulimia, and revision, ie identifying the changes to break these unhealthy patterns.

CBT is based on the theory that thoughts about a situation affect a person’s actions. Similarly, actions impact on how one thinks and feels. Hence, it is necessary to change the act of thinking and behaviour concomitantly.

IPT is based on the theory that relationships with other people have a significant effect on a person’s mental health.

FPT is based on the theory that bulimia nervosa may be associated with unresolved past conflicts, usually in childhood, which are being re-enacted in adult life.

FT involves the patient and close family members discussing how bulimia nervosa has affected them, and the positive changes the patient and family can make.

CBT and IPT have been found to be effective in the management of bulimia nervosa. The type of treatment chosen may be based on personal preference and the availability of the services.

Medication is usually prescribed for associated depression. The antidepressants, fluoxetine, desimipramine and imipramine, have been found effective.

In addition to professional management, bulimia nervosa sufferers can develop coping skills like boosting self-esteem by learning new skills, developing a hobby, or involvement in social group activities; being realistic and not succumbing to hype frm the media or friends; refraining from dieting or omitting meals; and emulating healthy role models.

Bulimia nervosa sufferers can recover, but it may take a long time. They have to change the way they think about food, change their eating habits, and if necessary, gain weight safely.

The longer a person has had bulimia nervosa, the more difficult it is to recover. The recovery process in most sufferers goes through many stages in which progress involve forward and backward steps.

Source: Dr Milton Lum