Bulimia is a mental illness from the group of eating disorders characterized by bouts of uncontrolled copious food intake and subsequent violent emptying of the stomach. Patients periodically overeat, after which they experience feelings of guilt and self-hatred, resort to various methods of cleansing the body: provoke vomiting, use enemas, laxatives and diuretics. To reduce weight, strict diets and intense physical activity are used. Diagnosis of bulimia is performed clinically and with the help of psychodiagnostic questionnaires. Treatment includes psychotherapy, diet therapy and taking antidepressants.
ICD 10
F50.2 Bulimia nervosa
Bulimia meaning
The term “bulimia” comes from the Greek language, translated as “bovine hunger”. Active research of the disease has been conducted since the 1970s. Then the doctor from the USA J. Russell investigated cases of alternating overeating and refusal of food in university students and for the first time used the concept of “nervous bulimia”. Synonymous names are kinorexia, neurogenic bulimia, wolf hunger. This disorder occurs 2-3 times more often than anorexia. Epidemiology among adolescents and young women is 1.6%, among men – 0.5%. The incidence is highest in the period from 15 to 24 years. About 90% of patients are girls and women whose weight is within the normal range or higher. Most of them are engaged in areas that require body weight control – dancers, gymnasts, models, runners.
Causes of bulimia
Bulimia is polymorphic by origin, there are internal and external, social, predisposing factors, as well as events that serve as a trigger for the onset of the disease. Most patients have a distorted perception of food, eating for them is a way to reduce emotional stress, not to satisfy hunger. The causes of the disease include:
- Somatic diseases. Attacks of uncontrolled gluttony can occur as a result of organic damage to some parts of the brain, for example, the food center or the frontal lobes of the cortex. Pathologically increased appetite is also observed in metabolic disorders: insulin resistance, diabetes mellitus and hyperthyroidism.
- Emotional and personal characteristics. Bulimia is more often diagnosed in people with increased responsibility, low self-esteem, instability of the image of the physical and personal “I”. They are prone to prolonged affective stress, suffer from feelings of hopelessness, helplessness and guilt.
- Habits, upbringing. Overeating can be a behavioral pattern transferred from childhood, from the parental family into adulthood. The risk of developing the disease is higher with the requirements of parents to finish a portion, with a ban on the release of leftovers.
- Stress. The absorption of delicious food helps to reduce unpleasant emotional experiences. Seizures occur more often after exposure to stressful factors: quarrels with loved ones, high academic or work load, lack of time.
Pathogenesis
Periodic uncontrolled overeating is formed on the basis of emotional tension according to the type of addictive behavior. Bulimic attacks are preceded by an increase in affective discomfort: anxiety, sadness, anger. The more intense the negative emotion, the stronger the hunger. During the meal, a short-term period of euphoria develops, the tension disappears. Patients are unable to control the absorption of food, do not feel the moment of saturation, stop eating when nausea, feelings of bursting, heaviness and abdominal pain appear. Euphoria is replaced by feelings of guilt, anger and contempt for their own habits. Attempts to return to the previous state are realized by provoking vomiting, taking laxatives and diuretics. After emptying the gastrointestinal tract, affective experiences weaken. After a while, the attack repeats. Thus, overeating becomes a regulator of the emotional life of patients.
Classification
Traditionally, bulimia is divided into two types: purifying or classical, and non-purifying. In the first case, patients abuse enemas, provoke an attack of vomiting, take diuretics and laxatives. Non-purifying bulimia is less common, overeating is compensated by hunger strike, active sports. According to the nature of attacks of gluttony, there are three types of the disease:
- Paroxysmal. Periods of absorption of large amounts of food occur suddenly after some time after the “procedures” of purification. The duration of time without gluttony ranges from 6-12 hours to several days.
- Constant. Overeating is replaced by cleansing, almost immediately the appetite increases again. It is difficult to isolate seizures, patients consume food almost continuously.
- Night. Attacks of hunger and gluttony develop at night. In the daytime, the appetite is normal or reduced.
Symptoms of bulimia
The main clinical sign is bouts of overeating. Patients consume a large amount of food in a short period of time. Appetite increases suddenly, against the background of emotional discomfort caused by external or internal reasons: quarrels, failures, unpleasant memories. The behavior of patients becomes impulsive, aimed at finding an opportunity to retire and satisfy hunger. They choose foods with the highest fat and carbohydrate content – cakes, cakes, side dishes with sauce and meat. The process of absorbing food, as a rule, occurs alone, cannot be controlled, is accompanied by a feeling of joy, euphoria, relief after tension.
Patients do not feel the moment of saturation, continue to eat until the food runs out or pronounced physiological symptoms of overeating appear, such as nausea, abdominal pain, bloating and a feeling of bursting. At one time, patients receive several thousand calories, which exceeds their daily energy needs. After an attack of gluttony, there is irritation, anger, self-hatred, guilt for what he did, fear of weight gain. Compensating behavior is implemented to reduce negative experiences. It includes a variety of ways to get rid of what is eaten: mechanical and chemical provocation of vomiting, enema procedures, taking diuretics and laxatives. To avoid weight gain, patients practice fasting and actively exercise.
In many patients, body weight corresponds to the norm or exceeds it somewhat. At the same time, patients are overly concerned about imaginary or real excess weight, are not satisfied with the shape of the body, are dissatisfied with the appearance and strive to lose weight. Typical behavior is eating low–calorie diet meals in the presence of other people and then gluttony with high-calorie foods in privacy. Unlike anorexia nervosa with bulimia, patients are more critical of their condition, are aware of the presence of an eating disorder, feel regret and guilt, more often admit to others that they have the disease and related experiences. Due to this, they are less socially isolated, less likely to commit impulsive acts unrelated to nutrition, less prone to depression, drug addiction and alcoholism. Anxiety disorders in bulimics are more common.
Complications
Forced emptying of the stomach and intestines leads to the development of persistent somatic diseases. Vomiting, increased diuresis and diarrhea provoke dehydration, violation of the water-electrolyte balance and renal failure. Overeating and frequent vomiting can cause rupture of the esophagus or stomach. Vomit damages tooth enamel, increases the risk of tooth decay and gum disease. Abuse of laxatives forms dependence, intestinal hypotension, constipation. Cardiovascular diseases – arrhythmias, cardiomyopathies – are caused by magnesium and potassium deficiency, prolonged use of ipecacuanha syrup (emetic). On the part of the emotional and personal sphere, complications of bulimia are represented by affective bipolar and obsessive-compulsive disorders.
Diagnostics
The diagnosis is established on the basis of clinical and anamnestic data obtained during a conversation between a psychiatrist or a psychotherapist with a patient and his relatives. Among the symptoms, the clinician identifies neurotic (depression, self-blame, anxiety), somatic (weight changes, digestive disorders) and behavioral (overeating, provocation of diarrhea, vomiting). Additionally, specific psychodiagnostic questionnaires can be used, for example, the EAT-26 Attitude Test. Differential diagnosis involves distinguishing bulimia with gastrointestinal diseases leading to recurrent vomiting, and with psychopathological personality disorders accompanied by a kind of deviant behavior. To confirm the diagnosis , it is necessary to identify the presence of three clinical criteria:
- Periodic overeating. Episodes of gluttony are observed at least once a week for 3 months or more. The consumption of a large amount of food is accompanied by loss of control, inability to feel the moment of saturation.
- Recurrent compensatory behavior. At least once a week for 3 months there are behavioral episodes aimed at ridding the body of food and / or weight loss. This category includes vomiting, taking anorexics, diuretics, laxatives, periods of fasting, intensive training.
- Neurotic experiences. The motivation, interests and thoughts of patients are concentrated around excess weight, body shape and appearance. The fear of obesity, the dependence of self-esteem on appearance and body weight is determined.
Treatment for bulimia
With complex therapy, most disorders are reversible. Treatment should be carried out by a psychiatrist, a psychotherapist and a nutritionist. In the presence of complications, the help of narrow specialists is required – a gastroenterologist, dentist, cardiologist. In most cases, all activities are performed on an outpatient basis. They are aimed at stabilizing the somatic state, restoring normal appetite, reducing behavioral episodes of gastrointestinal cleansing. The following treatment methods are considered the most effective:
- Behavioral psychotherapy. Sessions of cognitive behavioral therapy increase the motivation of the patient to a normal diet, reduce anxiety about appearance and weight, eliminate the desire to overeat. The psychotherapist helps to master productive ways of coping with stress, introduce and consolidate the right eating habits. The effectiveness of this method with isolated application reaches 50%, with an integrated approach – higher.
- Interpersonal psychotherapy. The basis of treatment is the identification and resolution of personal problems that provoke bulimia. Sessions are held individually and in groups. Increasing the patient’s self-esteem, his social activity allows replacing an unproductive way of relieving tension (gluttony) with useful ones.
- Taking SSRIs. Selective serotonin reuptake inhibitors act as antidepressants, reducing anxiety and depression in patients. They also have a slight anorexigenic effect – they reduce appetite and cravings for high-calorie foods. When taking medications, the frequency of overeating and vomiting decreases.
Prognosis and prevention
Complex treatment of bulimia takes 4-8 months, but provides high efficiency – 80% of patients are completely cured of pathological eating habits. Despite this, increased attention to body weight and meals remains, which increases the risk of relapse. The main preventive measure is the right attitude to food and appearance in the family. The habit of healthy eating is formed on the basis of a child’s stable self-esteem, his self-confidence. It is forbidden to use food to reward success or to deprive food as punishment for mistakes and disobedience.
Literature
- Bulimia nervosa and binge-eating disorder in adolescents. Schneider M. Adolesc Med. 2003 Feb;14(1):119-31. link
- “Diagnostic shift” from eating disorder not otherwise specified to bulimia nervosa using DSM-5 criteria: a clinical comparison with DSM-IV bulimia. MacDonald DE, McFarlane TL, Olmsted MP. Eat Behav. 2014 Jan;15(1):60-2. link
- Eating disorders and depressive symptoms: an epidemiological study in a male population. Valls M, Callahan S, Rousseau A, Chabrol H. Encephale. 2014 Jun;40(3):223-30.
- Eating disorders in adolescents: how does the DSM-5 change the diagnosis? Fisher M, Gonzalez M, Malizio J. Int J Adolesc Med Health. 2015 Nov;27(4):437-41. link
- Should binge eating disorder be included in the DSM-V? A critical review of the state of the evidence. Striegel-Moore RH, Franko DL. Annu Rev Clin Psychol. 2008;4:305-24. link
