Eating Disorders

10.2 Bulimia Nervosa

Marya Hornbacher describes her descent into bulimia nervosa:

I woke up one morning with a body that seemed to fill the room. Long since having decided I was fat, it was a complete crisis when my body, like all girls’ bodies, acquired a significantly greater number of actual fat cells than it had ever possessed. At puberty, what had been a nagging, underlying discomfort with my body became a full-blown, constant obsession…. When I returned [from the bathroom after throwing up], everything was different. Everything was calm, and I felt very clean. Everything was in order. Everything was as it should be.

(1998, pp. 40–44)

For Hornbacher, as for many other people with bulimia, the maladaptive eating behaviors started as an attempt to cope with negative feelings about weight, appearance, or eating “too much.” In this section we examine the criteria for bulimia nervosa and the medical effects of the disorder.

What Is Bulimia Nervosa?

A key feature of bulimia nervosa (often simply referred to as bulimia) is repeated episodes of binge eating followed by inappropriate efforts to prevent weight gain. Such inappropriate efforts to prevent weight gain can include vomiting or using diuretics, laxatives, enemas, or engaging in other behaviors to prevent weight gain, such as fasting or excessive exercise.

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As noted earlier, some people with anorexia may purge or fast. In those cases, according to DSM-5, the symptom that distinguishes the two disorders is that people with anorexia have significantly low weight whereas those with bulimia do not. Bulimia is two to three times more prevalent than anorexia and, like anorexia, is much more prevalent among females than among males (American Psychiatric Association, 2013). Like people with anorexia, people with bulimia typically overvalue their appearance and body image (Crowther & Williams, 2011; Delinsky et al., 2011). The DSM-5 criteria for bulimia nervosa are presented in TABLE 10.3, and additional facts about the disorder are listed in TABLE 10.4.

Table : TABLE 10.3 • DSM-5 Diagnostic Criteria for Bulimia Nervosa

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

Table : TABLE 10.4 • Bulimia Nervosa Facts at a Glance

Prevalence

Over the course of a lifetime, 1–2% of women and 0.1–0.5% of men develop the disorder (Hoek & van Hoeken, 2003; Hudson et al., 2007).

Comorbidity

Up to 75% of people with bulimia have at least one other disorder, often an anxiety disorder or depression (Godart et al., 2003).

Onset

Bulimia usually begins in late adolescence or early adulthood.
People in more recent birth cohorts (that is, those born more recently) have a higher risk for developing bulimia (Hudson et al., 2007).

Course

At a 15-month follow-up, almost one third of people diagnosed with bulimia still met the criteria for the diagnosis; at a 5-year follow-up, that proportion dropped to 15% (Fairburn et al., 2000); other studies find similar results (Zeeck et al., 2011). However, people who no longer meet the DSM-5 criteria for the disorder may nevertheless continue to have persistent symptoms of bulimia, although not the number, frequency, or intensity specified by the criteria (Ben-Tovim, 2003; Keel et al., 1999).
People who have less intense negative attitudes about their bodies and who function better in daily life are more likely to have a healthier outcome (Ben-Tovim, 2003; Keel et al., 1999).

Gender Differences

Approximately 75–90% of people who have bulimia nervosa are female (Hoek & van Hoeken, 2003; Hudson et al., 2007).

Cultural Differences

Some studies find significant differences in prevalence, frequency, and symptoms of eating disorders across ethnic groups within the United States. Specifically, Black and Hispanic American women are less likely to be diagnosed with bulimia than are Asian American or White American women (Alegría et al., 2007; Nicdao et al., 2007; Taylor et al., 2007).

Source: Unless otherwise noted, the source for information is American Psychiatric Association, 2013.

Often, people with bulimia don’t simply eat normally at meals and then binge between meals (Walsh, 1993). Rather, they try to control what they eat, restricting their caloric intake at meals (trying to be “good” and eat less), but later they become ravenous, and their hunger feels out of control. They then binge eat, which in turn makes them feel physically and emotionally “bad” because they “lost control” of themselves. As a result of such feelings, they may purge and subsequently strive to eat less, restricting their caloric intake at meals and creating a vicious cycle of restricting, bingeing, and usually purging (Fitzgibbon & Stolley, 2000). In Case 10.2, Gabriella presents a similar story.

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CASE 10.2 • FROM THE OUTSIDE: Bulimia Nervosa

[Gabriella is] a young Mexican woman whose parents moved to the U.S. when she was just a child. While her mother and father continue to speak Spanish at home and place a high value on maintaining their Mexican traditions, Gabriella wants nothing more than to fit in with her friends at school. She chooses to speak only English, looks to mainstream fashion magazines to guide her clothing and make-up choices, and wants desperately to have a fashion-model figure. In an attempt to lose weight, Gabriella has made a vow to herself to eat only one meal a day—dinner—but on her return home from school, she is rarely able to endure her hunger until dinnertime. She often loses control and ends up “eating whatever I can get my hands on.” Frantic to keep her problem hidden from her family, she races to the store to replace all the food she has eaten.

(Fitzgibbon & Stolley, 2000)

Medical Effects of Bulimia Nervosa

Frequent vomiting can permanently erode dental enamel, shown here, and lead to cavities and related problems.

Like anorexia, bulimia can lead to significant physical changes and medical problems. For instance, chronic vomiting, a purging method used by Marya Hornbacher, can cause the parotid and salivary glands (in the jaw area) to swell (creating a kind of “chipmunk” look) and can erode dental enamel, making teeth more vulnerable to cavities and other problems. People who use syrup of ipecac to induce vomiting may develop heart and muscle problems (Pomeroy, 2004; Silber, 2004).

Furthermore, many people with bulimia use laxatives regularly, which can lead to a permanent loss of intestinal functioning as the body comes to depend on the chemical laxatives to digest food and eliminate waste. In such cases, the malfunctioning intestinal section must be surgically removed (Pomeroy, 2004). Bulimia can also produce constipation, abdominal bloating and discomfort, fatigue, and irregular menstruation (Mascolo et al., 2012; Pomeroy, 2004). As noted earlier, in the section on anorexia, all forms of purging can cause dehydration and an imbalance of the body’s electrolytes, which disrupt normal neural transmission and heart contractions. The medical effects of bulimia can create significant—and enduring—problems, as they did for the woman in Case 10.3.

CASE 10.3 • FROM THE INSIDE: Bulimia Nervosa

A 32-year-old woman describes how bulimia nervosa has affected her:

My life revolves around food and exercise. Because of my abuse of diet pills and purging, I had a stroke when I was 23. I now have headaches. I am at risk of having another stroke, and this time I have a high chance of not coming out of it. Emotionally, it’s a daily battle. I’m depressed because I want to eat, and I’m depressed because I know if I do eat, I’ll get fat and gain all the weight back that I have lost.

Everyone around me is terrified that I may die from this, and it has put a lot of stress on my marriage. I have no bedroom life anymore because I refuse to let my husband touch me or even look at my body. My kids are affected greatly by it because I usually have no energy to do anything with them, and when I do have energy, I am staying busy to burn the calories I have put in my body.

(Anonymous, 2003, p. 382)

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Is Bulimia Distinct From Anorexia?

About half of people with anorexia go on to develop bulimia (Bulik et al., 1997; Tozzi et al., 2005), which may indicate that anorexia and bulimia are not distinct but rather represent phases of the same eating disorder, with the symptoms shifting over time. Some researchers have argued that a person’s diagnosis may better reflect where she is in the course of the eating disorder at the time she is diagnosed (Fairburn & Cooper, 2011). In fact, the characteristics of the binge eating/purging type of anorexia have more in common with bulimia than with the restricting type of anorexia (Gleaves, Lowe, Snow, et al., 2000; Peterson et al., 2011). All that distinguishes the binge eating/purging type of anorexia from bulimia is the low weight.