Bulimia Nervosa 

  • Author: Christine I Osterhout, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Nov 15, 2011
 

Background

Bulimia nervosa is an eating disorder delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).[1] The word bulimia is derived from the Greek words bous (ox) and limos (hunger), indicating a state of excessive hunger. Among the eating disorders, bulimia nervosa and anorexia nervosa are far more common in young females, while binge-eating disorder, the most common eating disorder overall, is more common in adults.

Bulimia nervosa includes regularly occurring compensatory behaviors that are intended to rid the body of the excess calories consumed during eating binges. Bulimia nervosa is distinguished from the recently delineated syndrome of binge-eating disorder, in which no regular or consistent compensatory behavior accompanies the bingeing episodes. The DSM-IV-TR recognizes 2 major variants of bulimia nervosa: purging (ie, compensation by means of self-induced vomiting and/or excessive ingestion of laxatives to induce diarrhea) and nonpurging (ie, binge eating associated with the use of nonpurging compensatory measures such as excessive exercise, stimulant substances, and/or fasting). The frequent association of cigarette smoking with bulimia nervosa may at times reflect compensatory behavior, in that nicotine use appears to suppress, whereas smoking cessation provokes weight gain in some individuals.

In up to 60% of cases, patients with bulimia nervosa report prior histories of anorexia nervosa. In contrast to individuals with uncomplicated binge-eating disorder who tend to be obese, people with bulimia nervosa are more typically of normal weight, although some degree of overlap between nonpurging bulimia nervosa and binge-eating disorder is seen. The natural history of eating disorders is such that individuals may pass through several diagnoses over time, with some meeting criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder at various points. The development of anorexia nervosa in individuals who initially present with bulimia nervosa is possible, although less common.[2]

Binge eating

Bulimia nervosa is characterized by frequent episodes of binge eating associated with emotional distress and a sense of loss of control.

Binge eating: Eating, in a discrete period of time (eg, 2 h) an amount of food that is significantly larger than is typical for most people during the same defined period. This behavior is associated with a perceived loss of control of eating during this time.

Overeating episode: The consumption of an unusually large amount of food in a defined period, without concomitant perception of loss of control.

Subjective bulimic episode: The consumption of objectively minimal amounts of food in a defined period with a perception of loss of control.

Compensatory behaviors

Compensatory behaviors used by individuals with bulimia nervosa include self-induced vomiting, laxative abuse, excessive exercise generally experienced as being joyless and/or compulsive, episodes of fasting or strict dieting, diuretic abuse, use of appetite suppressants, failure to use insulin in those with type I diabetes, and/or the use of medications intended to speed up metabolism (eg, thyroid hormone). DSM-IV-TR diagnostic criteria require episodes of binge eating that occur at least twice weekly for 3 months. Individuals with bulimia nervosa are also dissatisfied with their body shape, weight, or both.

Self-evaluation

Anorexia nervosa and bulimia nervosa are characterized by abnormalities in eating behaviors associated with a fear of weight gain and usually some degree of body image distortion (believing one looks much fatter than is actually the case). These are accompanied by associated abnormalities in mood and in perceptions of hunger and satiety. Disordered eating and weight control efforts can manifest as dietary restriction, binge eating, and/or other compensatory behaviors intended to prevent weight gain, as noted above.

For more information, see Medscape's Eating Disorders Resource Center.

Diagnostic Criteria for 307.51 Bulimia Nervosa DSM-IV-TR* [1]

    Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
    1. Eating, in a discrete period of time (eg, within any 2-h period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
    2. A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
  1. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
  2. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
  3. Self-evaluation is unduly influenced by body shape and weight.
  4. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify type:

  • Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
  • Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2000). American Psychiatric Association.

*Note: Diagnostic criteria are subject to change in the DSM-V. A release of the final, approved DSM-V is expected in May 2013. Proposed changes and updates may be viewed at www.dsm5.org.[3]

Case study

A 21-year-old woman is brought into an outpatient clinic by her mother, who complains that her daughter has been demonstrating unusual eating patterns since she moved back home 6 months ago. Her mother observes her to eat large amounts of food, such as desserts, when she is alone, often finding food wrappers hidden in her daughter’s room. She is worried that her daughter may be engaging in vomiting after these episodes of heavy eating. She often isolates herself in the bathroom for 10-20 minutes after a large meal. This case will be discussed in the Clinical History section.

Next

Epidemiology

Frequency

United States

Bulimia nervosa is thought to be significantly underrecognized. In the United States, the prevalence of bulimia nervosa is 1%.[4] Lifetime prevalence is 0.5% for males and 1.5% for females. Those who are diagnosed with bulimia nervosa spend approximately 8.3 years with an episode. Approximately 65.3% of patients with bulimia have a body mass index (BMI) between 18.5-29.9 and only 3.5% have a BMI less than 18.5.

Bulimia nervosa is more common among those whose occupation or hobbies require gaining and/or losing weight rapidly, such as wrestlers and competitive bodybuilders.[5] Athletes in certain sports (eg, runners and gymnasts, are particularly prone to eating disorders.[6] The female athlete triad of eating disorders, hypothalamic amenorrhea, and osteoporosis is now well recognized and is particularly common in sports where slimness and body shape are of great importance, such as gymnastics, long distance running, diving, and figure skating. Eating disorders are also being recognized as a problem in predominantly male sports such as cycling, weight lifting, and wrestling. Certain vocations such as acting, modeling, and ballet dancing[7] also appear to be associated with higher risk for these disorders.

While overall epidemiological trends are difficult to assess given the changes in diagnostic criteria over time, most studies report a progressive increase in the prevalence of anorexia nervosa and bulimia nervosa in the last several decades of the 20th century, with the possibility that rates have been leveling off. However, along with increases in obesity, rates of binge eating disorder are believed to be on the rise as well.

Rates of bulimic symptoms (as distinct from the diagnosis of bulimia nervosa per se) may vary across geographic regions in the United States. In one small study, women from North Carolina and Virginia (South Atlantic region) reported more bulimic symptoms than women from Louisiana and Tennessee (South Central region) and Ohio and Missouri (Midwest region).[8]

Mortality/Morbidity

A meta-analysis conducted of 36 studies by Arcelus et al suggests that individuals with eating disorders have significantly elevated mortality rates. Furthermore, the patients with anorexia nervosa had the highest mortality rate.[9]

Race

Bulimia nervosa is a cosmopolitan disorder that has been described in all ethnic, racial, and socioeconomic groups. Literature is mixed regarding ethnic differences in eating disorders. No clear consensus exists about the relative prevalence of eating disorders and associated symptoms across ethnicities. Clinicians should remain alert for possible ethnic diversity in symptom presentation or distress that could obscure the diagnosis or need for intervention.[10, 11]

Sex

As with other eating disorders, bulimia nervosa occurs predominantly in women. Most reports suggest a female-to-male ratio of 10:1, with reported ranges from 20:1 to 7:1. In some populations (eg, active duty military) body dissatisfaction and subclinical eating disorder rates among males have been reported to be in excess of 20%.

Clinicians should remain aware that men also develop bulimia nervosa and other eating disorders. The psychopathology and attitudes of males with eating disorders appear on the whole to be similar to those of females with eating disorders; both are significantly associated with family histories of these disorders. Although few data are available, evidence suggests that men and women also share significant similarities in clinical course, complications, and response to treatment.

Age

The mean age of onset is 19.7, slightly older than the peak age of onset for anorexia nervosa but generally lower than the age of onset for binge-eating disorder. The prevalence of bulimia nervosa in children younger than 14 years appears to be less than 5%. Bulimia nervosa has also been reported in the elderly.[12]

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Christine I Osterhout, MD  Resident Physician, Department of Psychiatry and Behavioral Sciences, University of California, Davis Health System

Christine I Osterhout, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Lorin M Scher, MD  Health Sciences Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine

Lorin M Scher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Alpha Omega Alpha, American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Donald M Hilty, MD  Professor of Clinical Psychiatry, Vice-Chair of Faculty Development, Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine

Donald M Hilty, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Technology in Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Joel Yager  MD, Professor of Psychiatry, University of Colorado Health Sciences Center; Professor of Psychiatry Emeritus, University of California, Los Angeles, David Geffen School of Medicine; Professor of Psychiatry Emeritus, University of New Mexico School of Medicine

Joel Yager is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Gurze publishers Salary editing; Massachusetts Medical Society Salary Writing

Specialty Editor Board

Sarah C Aronson, MD  Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland

Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Gabriel I Uwaifo, MBBS and Robert C Daly, MB, ChB, MPH to the development and writing of this article.

The authors would also like to acknowledge the contributions of Rebecca Davis, Librarian at the University of California (UC), Davis and Dr. Eric Rickin, Director for the Center for Overcoming Problem Eating (COPE) at the Western Psychiatric Institute and Clinic, University of Pittsburgh, Medical Center. Finally, the authors thank the Department of Psychiatry and Behavioral Sciences at UC Davis.

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Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.
Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.
Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.
This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of C.J. Gostout, MD.
Table. Self-Help Books and Internet Resources on Eating Disorders
CBT-oriented workbooksAgras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (client workbook)
Agras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (therapist workbook)
Cash TF: The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA, New Harbinger, 1997
Fairburn C: Overcoming Binge Eating. New York, Guilford, 1995
Goodman LJ, Villapiano M: Eating Disorders:The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Goodman LJ, Villapiano M: Eating Disorders: Time for Change. Plans, Strategies, and Worksheets. New York, Brunner-Routledge, 2001 (therapist workbook)
Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 1993
Other books reported to be helpful by patients/familiesBulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005
Ellis A, Abrams M, Dengelegi L: The Art and Science of Rational Eating. Fort Lee, NJ, Barricade Books, 1992
Goodman LJ, Villapiano M: Eating Disorders: The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Hall L: Full Lives: Women Who Have Freed Themselves From Food and Weight Obsessions. Carlsbad, CA, Gürze Books, 1993
Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005
Michel DM, Willard SG: When Dieting Becomes Dangerous. New Haven, CT, Yale University Press, 2003
Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005
Zerbe K: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Carlsbad, CA, Gürze Books, 1995
Books reported to be helpful for male patientsAndersen AE, Cohn L, Holbrook T: Making Weight: Men's Conflicts With Food, Weight, Shape and Appearance. Carlsbad, CA, Gürze Books, 2000
Internet resources for health care professionalsAcademy for Eating Disorders (http://www.aedweb.org)
Internet resources for patients, families, and professionalsNational Eating Disorders Association (http://www.nationaleatingdisorders.org)National Association of Anorexia Nervosa and Associated Disorders (http://www.anad.org/site/anadweb/)
Eating Disorder Referral and Information Center (http://www.edreferral.com)
Something Fishy (http://www.something-fishy.org; a well-monitored advocacy site)
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