Eating Disorders: Bulimia Nervosa

Bulimia nervosa, commonly called bulimia, is an eating disorder. People with bulimia who want to lose weight try not to eat, but after a while they give in to the urge to eat. They will eat a large amount of food all at once. Almost immediately they will feel so worried that they will try to stop weight gain by such things as self-induced vomiting or by taking large amounts of laxatives to help them get rid of the food by having a bowel motion. This behaviour is often called a binge-purge cycle.

Bulimia normally starts with the person – most often, but not exclusively, a young woman, becoming worried about their weight and shape. This often happens around the time that puberty causes the normal changes to the body shape and weight. Dieting may cause a dramatic weight loss – about half of those who begin this process reach a low enough weight to have anorexia nervosa. The person then loses control of the dieting and begins the pattern of bingeing and purging. Weight gradually rises since the bingeing and purging does not usually keep it down. Many people with bulimia have normal weight but some are underweight and may continue to have anorexia as well – and some are overweight. About half of all cases of bulimia start before the age of 19, and almost all before the age of 45. Ninety percent of people with bulimia are women. Twenty three percent of women report bingeing quite often and 11 percent report purging. In about five percent of women this occurs often enough to be diagnosed as bulimia nervosa.

There is no clear information yet on the long-term outlook for those with bulimia. What we know at the moment is that after 10 years about 50 percent of people who have had bulimia are fully recovered; about 20 percent still have ongoing problems with bingeing and purging and 30 percent relapse from time to time. Studies which have been done so far have found that the death rate is three per 1000 people with bulimia, but many of the studies are so short that this figure is probably too low. Suicide can be a cause of death particularly for those people who have an associated depression. It is also known that people with bulimia stand a higher risk of developing depression, anxiety problems or alcohol and drug problems.

Signs of bulimia
Early signs of bulimia include:
• extreme concern about being too fat
• increasing isolation from others
• food disappearing from the house, especially high calorie foods
• spending long periods in the toilet especially immediately after meals, sometimes with the tap running for long periods
• shoplifting food
• swollen cheeks (a little like mumps) caused by swelling of the parotid gland
• excessive tooth decay – vomiting causes damage to tooth enamel
• a callous at the base of the index finger caused by repeatedly using the finger to vomit.

While bulimia does not appear to affect the person’s physical health, over a long period there are a number of serious complications which can occur:
• Repeated vomiting can lead to loss of tooth enamel, damage to the gullet and disturbances in body chemistry. At worst, low potassium levels can cause sudden death from cardiac arrest.
• Laxative abuse can lead to loss of normal bowel function which can cause enlargement of the large bowel and chronic constipation. It can also contribute to low potassium levels.
• Periods do not usually stop, but may be irregular.
Risk factors for developing bulimia
There are a number of groups who are at particular risk for developing bulimia:
• those whose career or sport requires them to be thin – dancers, gymnasts, models or body builders
• those who are overweight
• those with a number of different problems including childhood sexual abuse or neglect, drug or alcohol problems and unstable relationships
• people with diabetes
• those with problems of self-esteem and identity.

Causes of bulimia
We do not know what causes bulimia. There is no clear difference between those who get anorexia and those who get bulimia and they are best thought of as different forms of the same condition. Bulimia develops in certain situations.

Social situations. Bulimia has mainly become a problem for the western world in the last few decades. It does not occur in countries in which food is scarce, or in countries where women are not encouraged to be thin. In the west women have been given the message that they need to be thin to be considered beautiful. Since a thin shape is normal and healthy for only a very few women, others must either struggle with feelings of not being good, perfect or self-controlled enough or begin to diet.

Family and whanau situations. Those who develop bulimia have a higher than normal chance of having a close family or whanau member who has an eating disorder, depression, obsessive-compulsive disorder or alcohol problems. This may mean that there is a genetic aspect to bulimia, or that these families and whanau have emotional or other problems which make them more vulnerable to social pressures, or both. There may also be an increased chance of broken families and whanau and/or abuse within the families and whanau.

Individual situations. A number of writers have described emotional difficulties which they believe are common amongst those who have bulimia. Some stress the struggle people with bulimia have to feel in control of their lives. They turn to dieting as something they can feel completely in control of. Others have suggested that bulimia can be related to difficulties in growing up. People with bulimia often believe they developed it because things have gone wrong in their lives – it could be abandonment, sexual or physical abuse, being in an unhappy family whanau or not living up to people’s expectations. Other people with bulimia may agree with the view that there is genetic or biological aspect to their condition. A lot of people believe it is a combination of these things. Sometimes people think their problem is a punishment for their moral or spiritual failure. It’s important to remember that it is not your fault you have bulimia.

Families and whanau, especially parents, can worry that they caused their relative to develop bulimia. Sometimes they feel blamed by mental health professionals which can be very distressing for them. Most families and whanau want the best for their relative. It is important for them to understand what has contributed to their relative’s problem and to be able to discuss their own feelings about this without feeling guilty or blamed.

Living with Bulimia
Bulimia differs from anorexia in that it is much more able to be concealed. Sometimes people with bulimia say that they have had it for many years without family whanau or partners knowing anything about it. Generally the person feels very ashamed and disgusted by the vomiting. This leaves them feeling very isolated and vulnerable to depression and despair.

For family whanau bulimia is very puzzling and frustrating. They tend to feel helpless and find it hard to know how much to watch over the person with bulimia and how much to leave them alone. Often they feel lied to and sometimes they are angry about the amount of food that is ‘lost’. They may worry that the person with bulimia will die. Mothers, in particular, often feel guilty, responsible and angry with the child with bulimia for being difficult. Fathers often feel frustrated, closed out and unimportant.

Frequently, the parents cannot agree about the seriousness of the problem or what to do. Often one wants to be tougher while the other feels this will only make things worse. Brothers and sisters may feel ignored by parents whose attention is entirely taken up by the person with bulimia.

People with bulimia who are in a sexual relationship often report that the relationship is not satisfactory. Quite commonly, people with bulimia report having a number of unsuccessful relationships. It can be very important for the partner to understand the problem in order to be helpful. It is also important that the partner participates in dealing with the problem. This can be just as stressful for the partner who will need to make sure that they get plenty of support from family whanau and friends.

Treatment of Bulimia

Summary of treatment options
Overall the treatment of bulimia will depend on the severity of the symptoms and any associated emotional problems, such as depression, anxiety or alcohol abuse, the age of the person and the quality of their interpersonal relationships. A key issue in any psychological treatment is the person being able to work well with the clinician. In general, it is not helpful to combine different treatments or to have more than one therapist helping at any one time although it is common for people to try a number of
therapies. This can be useful since no treatment is clearly better than others and recovery is most likely where the patient mostly likes and understands the therapy. However, it is important to let the therapist know how you are feeling about the therapy and whether you are in another therapy.

Psychosocial treatments
These address the person’s thinking, behaviour, relationships and environment, including their culture.

Psychological therapies (often referred to as therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives. They may involve the use of specific therapies such as family therapy or individual therapies including cognitive-behavioural therapy (CBT), psychodynamic therapy, interpersonal therapy (ITP) or narrative therapy. Some therapists use feminist theories to encourage the person to become more aware of the importance of social pressures on her to be thin. More research is needed before one type of psychological therapy is necessarily preferred over another.

Psychoeducation is a process whereby the person is given information about their eating disorder and the complications of bulimia. This can be extremely important to help family whanau and friends to understand the person better and to aid improvement of the disorder.

Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem solving and information giving. All types of therapy/counselling should be provided to people and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Antidepressants have been found to be helpful in the treatment of bulimia. If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side-effects (short and long-term) are. If you are pregnant or breast feeding no medication is entirely safe. Before making any decisions about taking medication at this time you should talk with your doctor about the potential benefits and problems associated with each particular type of medication in pregnancy.

Hospitalisation may be suggested where there are serious concerns about the person’s physical health.

Complementary therapies
Complementary therapies which enhance the person’s life may be used in addition to psychosocial treatments and prescription medicines.

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