Bulimia nervosa

Last updated
Bulimia nervosa
Other namesBulimia
BulemiaEnamalLoss.JPG
Loss of enamel (acid erosion) from the inside of the upper front teeth as a result of bulimia
Specialty Psychiatry, clinical psychology
Symptoms 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]
Complications Breakdown of the teeth, depression, anxiety, substance use disorders, suicide [2] [3]
Causes Genetic and environmental factors [2] [4]
Diagnostic method Based on person's medical history [5]
Differential diagnosis Anorexia, binge eating disorder, Kleine-Levin syndrome, borderline personality disorder [5]
Treatment Cognitive behavioral therapy [2] [6]
Medication Selective serotonin reuptake inhibitors, tricyclic antidepressant [4] [7]
Prognosis Half recover over 10 years with treatment [4]
Frequency3.6 million (2015) [8]

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]

Contents

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]

Signs and symptoms

How bulimia affects the body Bulimiafaqdia.jpg
How bulimia affects the body
The erosion on the lower teeth was caused by bulimia. For comparison, the upper teeth were restored with porcelain veneers. Oral Manifestation of Bulimia..jpg
The erosion on the lower teeth was caused by bulimia. For comparison, the upper teeth were restored with porcelain veneers.

Bulimia typically involves rapid and out-of-control eating, which may stop when the person is interrupted by another person or the stomach hurts from over-extension, followed by self-induced vomiting or other forms of purging. This cycle may be repeated several times a week or, in more serious cases, several times a day [14] and may directly cause:

These are some of the many signs that may indicate whether someone has bulimia nervosa: [21]

As with many psychiatric illnesses, delusions can occur, in conjunction with other signs and symptoms, leaving the person with a false belief that is not ordinarily accepted by others. [23]

People with bulimia nervosa may also exercise to a point that excludes other activities. [23]

Interoceptive

People with bulimia exhibit several interoceptive deficits, in which one experiences impairment in recognizing and discriminating between internal sensations, feelings, and emotions. [24] People with bulimia may also react negatively to somatic and affective states. [25] Regarding interoceptive sensation, hyposensitive individuals may not detect normal feelings of fullness at the appropriate time while eating, and are prone to eating more calories in a short period of time as a result of this decreased sensitivity. [24]

Examining from a neural basis also connects elements of interoception and emotion; notable overlaps occur in the medial prefrontal cortex, anterior and posterior cingulate, and anterior insula cortices, which are linked to both interoception and emotional eating. [26]

People with bulimia are at a higher risk to have an affective disorder, such as depression or general anxiety disorder. One study found 70% had depression at some time in their lives (as opposed to 26% for adult females in the general population), rising to 88% for all affective disorders combined. [27] Another study in the Journal of Affective Disorders found that of the population of patients that were diagnosed with an eating disorder according to the DSM-V guidelines about 27% also suffered from bipolar disorder. Within this article, the majority of the patients were diagnosed with bulimia nervosa, the second most common condition reported was binge-eating disorder. [28] Some individuals with anorexia nervosa exhibit episodes of bulimic tendencies through purging (either through self-induced vomiting or laxatives) as a way to quickly remove food in their system. [29] There may be an increased risk for diabetes mellitus type 2. [30] Bulimia also has negative effects on a person's teeth due to the acid passed through the mouth from frequent vomiting causing acid erosion, mainly on the posterior dental surface.

Research has shown that there is a relationship between bulimia and narcissism. [31] [32] [33] According to a study by the Australian National University, eating disorders are more susceptible among vulnerable narcissists. This can be caused by a childhood in which inner feelings and thoughts were minimized by parents, leading to "a high focus on receiving validation from others to maintain a positive sense of self". [34]

The medical journal Borderline Personality Disorder and Emotion Dysregulation notes that a "substantial rate of patients with bulimia nervosa" also have Borderline personality disorder. [11]

A study by the Psychopharmacology Research Program of the University of Cincinnati College of Medicine "leaves little doubt that bipolar and eating disorders—particularly bulimia nervosa and bipolar II disorder—are related." The research shows that most clinical studies indicate that patients with bipolar disorder have higher rates of eating disorders, and vice versa. There is overlap in phenomenology, course, comorbidity, family history, and pharmacologic treatment response of these disorders. This is especially true of "eating dysregulation, mood dysregulation, impulsivity and compulsivity, craving for activity and/or exercise." [12]

Studies have shown a relationship between bulimia's effect on metabolic rate and caloric intake with thyroid dysfunction. [35]

Causes

Biological

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

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]

Diagnosis

The onset of bulimia nervosa is often during adolescence, between 13 and 20 years of age, and many cases have previously experienced obesity, with many relapsing in adulthood into episodic bingeing and purging even after initially successful treatment and remission. [61] A lifetime prevalence of 0.5 percent and 0.9 percent for adults and adolescents, respectively, is estimated among the United States population. [62] Bulimia nervosa may affect up to 1% of young women and, after 10 years of diagnosis, half will recover fully, a third will recover partially, and 10–20% will still have symptoms. [4]

Adolescents with bulimia nervosa are more likely to have self-imposed perfectionism and compulsivity issues in eating compared to their peers. This means that the high expectations and unrealistic goals that these individuals set for themselves are internally motivated rather than by social views or expectations. [63]

Criteria

Bulimia nervosa can be difficult to detect, compared to anorexia nervosa, because bulimics tend to be of average or slightly above average weight. Many bulimics may also engage in significantly disordered eating and exercise patterns without meeting the full diagnostic criteria for bulimia nervosa. [64] Recently, the Diagnostic and Statistical Manual of Mental Disorders was revised, which resulted in the loosening of criteria regarding the diagnoses of bulimia nervosa and anorexia nervosa. [65] The diagnostic criteria utilized by the DSM-5 includes repetitive episodes of binge eating (a discrete episode of overeating during which the individual feels out of control of consumption) compensated for by excessive or inappropriate measures taken to avoid gaining weight. [66] The diagnosis also requires the episodes of compensatory behaviors and binge eating to happen a minimum of once a week for a consistent time period of 3 months. [67] The diagnosis is made only when the behavior is not a part of the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on physical mass or appearance. Purging often is a common characteristic of a more severe case of bulimia nervosa. [68]

Treatment

There are two main types of treatment given to those with bulimia nervosa; psychopharmacological and psychosocial treatments. [69]

Psychotherapy

Cognitive behavioral therapy is the primary treatment for bulimia. [2] [6] Antidepressants of the selective serotonin reuptake inhibitor (SSRI) or tricyclic antidepressant classes may have a modest benefit. [4] [7] While outcomes with bulimia are typically better than in those with anorexia, the risk of death among those affected is higher than that of the general population. [3] At 10 years after receiving treatment about 50% of people are fully recovered. [4]

Cognitive behavioral therapy (CBT), which involves teaching a person to challenge automatic thoughts and engage in behavioral experiments (for example, in session eating of "forbidden foods") has a small amount of evidence supporting its use. [70]

By using CBT people record how much food they eat and periods of vomiting with the purpose of identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular basis. [71] Barker (2003) states that research has found 40–60% of people using cognitive behaviour therapy to become symptom free. He states in order for the therapy to work, all parties must work together to discuss, record and develop coping strategies. Barker (2003) claims by making people aware of their actions they will think of alternatives. [72] [73] People undergoing CBT who exhibit early behavioral changes are most likely to achieve the best treatment outcomes in the long run. [74] Researchers have also reported some positive outcomes for interpersonal psychotherapy and dialectical behavior therapy. [75] [76]

Maudsley family therapy, developed at the Maudsley Hospital in London for the treatment of anorexia, has been shown promising results in bulimia. [77]

The use of CBT has been shown to be quite effective for treating bulimia nervosa (BN) in adults, but little research has been done on effective treatments of BN for adolescents. [78] Although CBT is seen as more cost-efficient and helps individuals with BN in self-guided care, Family Based Treatment (FBT) might be more helpful to younger adolescents who need more support and guidance from their families. [79] Adolescents are at the stage where their brains are still quite malleable and developing gradually. [80] Therefore, young adolescents with BN are less likely to realize the detrimental consequences of becoming bulimic and have less motivation to change, [81] which is why FBT would be useful to have families intervene and support the teens. [78] Working with BN patients and their families in FBT can empower the families by having them involved in their adolescent's food choices and behaviors, taking more control of the situation in the beginning and gradually letting the adolescent become more autonomous when they have learned healthier eating habits. [78]

Medication

Antidepressants of the selective serotonin reuptake inhibitors (SSRI) class may have a modest benefit. [7] This includes fluoxetine, also known as prozac, which is FDA approved, for the treatment of bulimia, other antidepressants such as sertraline may also be effective against bulimia. Topiramate may also be useful but has greater side effects. [7] Compared to placebo, the use of a single antidepressant has been shown to be effective. [82] Combining medication with counseling can improve outcomes in some circumstances. [83] Some positive outcomes of treatments can include: abstinence from binge eating, a decrease in obsessive behaviors to lose weight and in shape preoccupation, less severe psychiatric symptoms, a desire to counter the effects of binge eating, as well as an improvement in social functioning and reduced relapse rates. [4]

Alternative medicine

Some researchers have also claimed positive outcomes in hypnotherapy. [84] The first use of hypnotherapy in Bulimic patients was in 1981. When it comes to hypnotherapy, Bulimic patients are easier to hypnotize than Anorexia Nervosa patients. In Bulimic patients, hypnotherapy focuses on learning self-control when it comes to binging and vomiting, strengthening stimulus control techniques, enhancing ones ego, improving weight control, and helping overweight patients see their body differently (have a different image). [85]

Risk factors

Being female and having bulimia nervosa takes a toll on mental health. Women frequently reported an onset of anxiety at the same time of the onset of bulimia nervosa. [86] The approximate female-to-male ratio of diagnosis is 10:1. [5] In addition to cognitive, genetic, and environmental factors, childhood gastrointestinal problems and early pubertal maturation also increase the likelihood of developing bulimia nervosa. [87] Another concern with eating disorders is developing a coexisting substance use disorder. [88]

Epidemiology

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Deaths due to eating disorders per million persons in 2012
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There is little data on the percentage of people with bulimia in general populations. [5] Most studies conducted thus far have been on convenience samples from hospital patients, high school or university students; research on bulimia nervosa among ethnic minorities has also been limited. [89] Existing studies have yielded a wide range of results: between 0.1% and 1.4% of males, and between 0.3% and 9.4% of females. [90] Studies on time trends in the prevalence of bulimia nervosa have also yielded inconsistent results. [91] According to Gelder, Mayou and Geddes (2005) bulimia nervosa is prevalent between 1 and 2 percent of women aged 15–40 years. Bulimia nervosa occurs more frequently in developed countries [71] and in cities, with one study finding that bulimia is five times more prevalent in cities than in rural areas. [92] There is a perception that bulimia is most prevalent amongst girls from middle-class families; [93] however, in a 2009 study girls from families in the lowest income bracket studied were 153 percent more likely to be bulimic than girls from the highest income bracket. [94] According to a study conducted in 2022 by Silen et al., which conglomerated statistics using various methods such as SCID, MRFS, EDE, SSAGA, and EDDI, the USA, Finland, Australia, and the Netherlands had an estimated 2.1%, 2.4%, 1.0%, and 0.8% prevalence of bulimia nervosa among females under 30 years of age [95] . This demonstrates the prevalence of bulimia nervosa in developed, Western, first-world countries, indicating an urgency in treating adolescent women. Additionally, these statistics may be misrepresentative of the true population affected with bulimia nervosa due to potential underreporting bias.

There are higher rates of eating disorders in groups involved in activities which idealize a slim physique, such as dance, [96] gymnastics, modeling, cheerleading, running, acting, swimming, diving, rowing and figure skating. Bulimia is thought to be more prevalent among whites; [97] however, a more recent study showed that African-American teenage girls were 50 percent more likely than white girls to exhibit bulimic behavior, including both binging and purging. [98]

CountryYearSample size and type % affected
Portugal 20062,028 high school students0.3% female [99]
Brazil 20041,807 students (ages 7–19)0.8% male1.3% female [100]
Spain20042,509 female adolescents (ages 13–22)1.4% female [101]
Hungary2003580 Budapest residents0.4% male3.6% female [96]
Australia19984,200 high school students0.3% combined [102]
United States19961,152 college students0.2% male1.3% female [103]
Norway199519,067 psychiatric patients0.7% male7.3% female [104]
Canada19958,116 (random sample)0.1% male1.1% female [105]
Japan19952,597 high school students0.7% male1.9% female [106]
United States1992799 college students0.4% male5.1% female [107]

History

Etymology

The term bulimia comes from Greek βουλιμίαboulīmia, "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

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

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]

See also

Related Research Articles

An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health. Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.

<span class="mw-page-title-main">Rumination syndrome</span> Medical condition

Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation as there is with typical vomiting, and the regurgitated food is undigested. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities . It is increasingly being diagnosed in a greater number of otherwise healthy adolescents and adults, though there is a lack of awareness of the condition by doctors, patients, and the general public.

The Eating Attitudes Test, created by David Garner, is a widely used 26-item, standardized self-reported questionnaire of symptoms and concerns characteristic of eating disorders. The EAT is useful in assessing "eating disorder risk" in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which people avoid eating certain foods, or restrict their diets to the point it ultimately results in nutritional deficiencies. This can be due to the sensory characteristics of food, such as its appearance, smell, texture, or taste; due to fear of negative consequences such as choking or vomiting; having little interest in eating or food, or a combination of these factors. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.

Diabulimia, also known as ED-DMT1 in the US or T1ED in the UK, is an eating disorder in which people with type 1 diabetes deliberately give themselves less insulin than they need or stop taking it altogether for the purpose of weight loss. Diabulimia is not recognized as a formal psychiatric diagnosis in the DSM-5. Because of this, some in the medical or psychiatric communities use the phrases "disturbed eating behavior" or "disordered eating behavior" and disordered eating (DE) are quite common in medical and psychiatric literature addressing patients who have type 1 diabetes and manipulate insulin doses to control weight along with exhibiting bulimic behavior.

Purging disorder is an eating disorder characterized by the DSM-5 as self-induced vomiting, or misuse of laxatives, diuretics, or enemas to forcefully evacuate matter from the body. Purging disorder differs from bulimia nervosa (BN) because individuals do not consume a large amount of food before they purge. In current diagnostic systems, purging disorder is a form of other specified feeding or eating disorder. Research indicates that purging disorder, while not rare, is not as commonly found as anorexia nervosa or bulimia nervosa. This syndrome is associated with clinically significant levels of distress, and that it appears to be distinct from bulimia nervosa on measures of hunger and ability to control food intake. Some of the signs of purging disorder are frequent trips to the bathroom directly after a meal, frequent use of laxatives, and obsession over one's appearance and weight. Other signs include swollen cheeks, popped blood vessels in the eyes, and clear teeth which are all signs of excessive vomiting.

The Anorectic Behavior Observation Scale (ABOS) is a thirty-item diagnostic questionnaire devised to be answered by the parents, spouse or other family member of an individual suspected of having an eating disorder. It was developed by Vandereyken et al. in 1992. The ABOS is useful for evaluations of patients with anorexia nervosa (AN) and bulimia nervosa (BN) before, during, and after clinical treatments. It can also be a significant tool for the screening of subjects in early-stage ED.

Maudsley family therapy also known as family-based treatment or Maudsley approach, is a family therapy for the treatment of anorexia nervosa devised by Christopher Dare and colleagues at the Maudsley Hospital in London. A comparison of family to individual therapy was conducted with eighty anorexia patients. The study showed family therapy to be the more effective approach in patients under 18 and within 3 years of the onset of their illness. Subsequent research confirmed the efficacy of family-based treatment for teens with anorexia nervosa. Family-based treatment has been adapted for bulimia nervosa and showed promising results in a randomized controlled trial comparing it to supportive individual therapy.

<span class="mw-page-title-main">Anorexia nervosa</span> Type of eating disorder

Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.

The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.

<span class="mw-page-title-main">Eating disorders and memory</span> Memory impairments linked to eating disorders

Many memory impairments exist as a result from or cause of eating disorders. Eating disorders (EDs) are characterized by abnormal and disturbed eating patterns that affect the lives of the individuals who worry about their weight to the extreme. These abnormal eating patterns involve either inadequate or excessive food intake, affecting the individual's physical and mental health.

Cognitive behavioral therapy (CBT) is derived from both the cognitive and behavioral schools of psychology and focuses on the alteration of thoughts and actions with the goal of treating various disorders. The cognitive behavioral treatment of eating disorders emphasizes on the minimization of negative thoughts about body image and the act of eating, and attempts to alter negative and harmful behaviors that are involved in and perpetuate eating disorders. It also encourages the ability to tolerate negative thoughts and feelings as well as the ability to think about food and body perception in a multi-dimensional way. The emphasis is not only placed on altering cognition, but also on tangible practices like making goals and being rewarded for meeting those goals. CBT is a "time-limited and focused approach" which means that it is important for the patients of this type of therapy to have particular issues that they want to address when they begin treatment. CBT has also proven to be one of the most effective treatments for eating disorders.

Drunkorexia is a colloquialism for anorexia or bulimia combined with an alcohol use disorder. The term is generally used to denote the utilization of extreme weight control methods to compensate for planned binge drinking. Research on the combination of an eating disorder and binge drinking has primarily focused on college-aged women, though the phenomenon has also been noted among young men. Studies suggest that individuals engage in this combination of self-imposed malnutrition and binge drinking to avoid weight gain from alcohol, to save money for purchasing alcohol, and to facilitate alcohol intoxication.

Other specified feeding or eating disorder (OSFED) is a subclinical DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR. It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder. OSFED includes five examples:

Christopher James Alfred Granville Fairburn is a British psychiatrist and researcher. He is Emeritus Professor of Psychiatry at the University of Oxford. He is known for his research on the development, evaluation and dissemination of psychological treatments, especially for eating disorders.

Chew and spit is a compensatory behavior associated with several eating disorders that involves chewing food and spitting it out before swallowing, often as an attempt to avoid ingesting unwanted or unnecessary calories. CS can be used as a way to taste food viewed as “forbidden” or unhealthy. Individuals who partake in CS typically have an increased desire for thinness, increased loss of control (LOC) and body dissatisfaction. CS can replace vomiting and/or binging behaviors, or serve as an additional behavior to many eating disorders.

Body image disturbance (BID) is a common symptom in patients with eating disorders and is characterized by an altered perception of one's own body.

Body checking is a compulsive behaviour related but not exclusive to various forms of body dysmorphic disorders. It involves frequently collecting various information about one’s own body in terms of size, shape, appearance or weight. Frequent expressions of this form of behaviour entails for example mirror checking, trying to feel one’s own bones, pinching the abdomen, frequent body weight measurement and comparing your own body to that of others. Studies have shown that an increased rate of body checking correlates with an overall increased dissatisfaction with the own body.

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