Bulimia, more accurately known as Bulimia Nervosa, is an eating disorder characterized by three primary symptoms: recurrent episodes of binge eating, inappropriate compensatory behaviors, and extreme concern about body weight and shape. Binge eating involves the consumption of a large amount of food in a relatively short period of time along with a perception of loss of control over eating. Binge eating may be triggered by a number of factors, including hunger, negative mood, interpersonal stressors, and thoughts about weight and shape. Inappropriate compensatory behaviors are strategies aimed at controlling body weight and shape, including self-induced vomiting, misuse of laxatives and/or diuretics, excessive exercising, and fasting. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) divides Bulimia Nervosa into two subtypes. The purging subtype is distinguished by the presence of purging compensatory behaviors such as self-induced vomiting or laxative misuse. The nonpurging subtype is diagnosed in the presence of only nonpurging compensatory behaviors (e.g., excessive exercise). Individuals with Bulimia Nervosa also exhibit overconcern about their body weight and shape and usually engage in extreme dietary restriction outside of binge-eating episodes in order to control weight and shape. The dysfunctional concerns about weight and shape are typically conceptualized as the central feature or core psychopathology of Bulimia Nervosa.
Bulimia Nervosa typically begins with rigid and unhealthy dieting that is motivated by the desire to be thin and lose weight. Individuals with Bulimia Nervosa attempt to limit the amount and type of food that they consume, particularly during the early stages of the disorder. Over time, they become increasingly preoccupied with thoughts of food, and episodes of binge eating alternate with periods of restriction. Vomiting, laxative misuse, and other inappropriate compensatory behaviors usually follow the onset of binge eating.
Bulimia Nervosa most commonly occurs in women and usually begins in adolescence or early adulthood. Approximately 1-2% of young women meet criteria for the disorder. In contrast to Anorexia Nervosa, individuals with Bulimia Nervosa maintain normal weight. As a result, Bulimia Nervosa is more difficult to detect than Anorexia Nervosa as physical signs are not readily apparent to the casual observer. Bulimia is often a secretive disorder, and individuals with Bulimia Nervosa typically experience guilt and shame about their behavior. Individuals with Bulimia Nervosa display rigid patterns of thinking and tend to view the world and their experiences from an "all or nothing" perspective. For example, bulimics often describe eating as being either "in control" or "out of control" and weight or appearance as either "thin" or "fat."
The medical complications associated with Bulimia Nervosa are generally regarded as less severe than those associated with the low body weight of Anorexia Nervosa. Electrolyte disturbances represent the most serious medical complication and may lead to cardiac irregularities and, in some cases, heart failure. Inflammation and rupture of the esophagus is another serious potential complication resulting from repeated vomiting. Additional medical complications include laxative dependence, fatigue, enlarge ment of salivary glands leading to puffy cheeks, headaches, dry skin, abrasions to fingers from inducing vomiting, and dental erosion.
Numerous causal factors have been proposed as being related to the development of Bulimia Nervosa. Disturbances in such neurotransmitter systems as those of serotonin and norepinephrine have been observed, but it remains unclear whether these biological irregularities cause Bulimia Nervosa or result from the disturbed eating behaviors that characterize the disorder. Findings from several studies suggest that Bulimia Nervosa may result, in part, from dieting-based changes in serotonin functioning in vulnerable individuals. Neurochemical abnormalities appear to persist after recovery. A genetic basis for bulimia is supported by family studies, which examine the clustering of disorders within families. Family studies find increased rates of eating disorders in the families of individuals with Bulimia Nervosa as compared to the families of individuals without Bulimia Nervosa. The exact role genetic factors play in the development of Bulimia Nervosa, however, remains unclear, and environmental factors clearly influence the development of the disorder.
Although it is widely believed that childhood sexual abuse causes Bulimia Nervosa, there is little evidence for a specific relationship between a history of sexual abuse and the development of the disorder. Childhood sexual abuse appears to increase one's risk for psychological disorders in general, not Bulimia Nervosa specifically. Cultural factors do appear to play a role in the development of Bulimia Nervosa. The ideal female weight in Western society, often referred to as the thin ideal, has continued to decrease even as the average female weight increases. As a result, more and more women experience normative body dissatisfaction secondary to a discrepancy between their ideal and actual weight. Body dissatisfaction is widespread among adolescent girls, and research links body dissatisfaction, along with acceptance of the thin ideal, to the development of Bulimia Nervosa. Prospective research has also found a strong relationship between dieting and the later development of an eating disorder. Other potential risk factors include early onset of menstruation, a personal or parental history of obesity, parental dieting, and personality traits such as perfectionism. Bulimia Nervosa often co-occurs with other psychological disorders including depression, Anxiety Disorders, substance abuse disorders, or some Personality Disorders such as Borderline Personality Disorder.
According to the DSM-IV, Bulimia Nervosa is typically either intermittent, with binge eating and/or purging alternating with periods of remission, or chronic. Treatment, however, can significantly affect outcome. Cognitive-behavioral therapy (CBT), a psychological treatment, is widely viewed as the treatment of choice for Bulimia Nervosa. CBT for Bulimia Nervosa includes education about Bulimia Nervosa, self-monitoring of eating behaviors, establishing a regular pattern of eating, strategies to reduce binge eating and compensatory behaviors (e.g., vomiting), problem solving, and cognitive restructuring. Cognitive restructuring is a strategy designed to help patients identify and challenge their patterns of thinking. Numerous studies have demonstrated that the majority of patients treated with CBT benefit from treatment and that improvement is maintained over time. Interpersonal psychotherapy is another psychological treatment that is supported by research, although fewer studies have examined this form of psychotherapy. Antidepressant medications also appear to reduce bulimic symptoms.
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