Bulimia

Dr Suki Greaves discusses bulimia nervosa, an eating disorder which has become increasingly prevalent and which needs a multifactorial management approach. This is followed by a commentary on the stigma of eating disorders by Professor Simon Gowers

Bulimia nervosa (or dietary chaos syndrome) has become increasingly common over the last two to three decades. Approximately one to two per cent of British women are thought to suffer from bulimia nervosa, male cases being relatively rare. There is a clear relationship between bulimia nervosa and anorexia nervosa; bulimia nervosa being more common. About 30 per cent of bulimia nervosa cases have a prior history of anorexia nervosa; it is now the commonest eating disorder encountered in psychiatry.

Clinical features

Most cases of bulimia nervosa present in their late teens or early twenties. Most are female. Those that are male often have a history of premorbid obesity and are often homosexual. Many sufferers have a history of dietary difficulties and harbour overvalued ideas concerning weight and shape. They often constantly ruminate over their body image which they see as overweight and unattractive. In order to counteract these feelings, they indulge in methods aimed at weight loss. These include self-induced vomiting, purgative abuse, diuretic or stimulant misuse and excessive exercising. They will also undertake periods of starvation which alternate with overeating. The type of food chosen to binge on will usually be carbohydrate-rich food, normally avoided by the patient who sees it as fattening or 'forbidden'. As many as 10 bulimic episodes may occur in one day, the total amount eaten per episode being up to 3000 kilocalories. Bouts of overeating may be precipitated by depression, boredom or anxiety. Afterwards, the patient usually describes a period of drowsiness, feelings of depression, guilt and self-disgust.

Physical features


Most sufferers of bulimia nervosa do not have major physical complaints. There may be irregular or absent menstruation, abdominal pain or lethargy. On examination, there may be parotid gland enlargement due to enforced vomiting, conferring a chubby appearance to the face. Other features include calluses on the dorsum of the hand due to self-induced vomiting and dental problems may arise due to erosion of dental enamel on the inner surface of the front teeth. This is due to acidic gastric content damaging the teeth, giving them a pitted appearance, a characteristic sign often recognised by dentists. The body weight of the patient, despite these harsh measures, often remains within normal limits. Biochemical complications as a result of repeated vomiting include potassium depletion leading, in turn, to general weakness, cardiac arrhythmias, renal damage, urinary infections and tetany. Epileptic fits may also occur.

Causes

Causes of bulimia nervosa are multi-factorial. Psychological factors include a history of depression and low self-esteem. Often sufferers describe a sense of loss of personal control. Substance misuse and alcohol misuse are also evident in those with bulimia nervosa and there is often a family history of depression. A more prominent cause seems to be that imposed upon women by society. Today, women are expected to conform to the 'thinness conscious culture'. There are also high expectations for women to be high achievers in the workplace, have families and still retain a sense of femininity. Overweight women are often thought of as second-rate citizens and regard themselves as failures in their personal and professional lives.

Management

Bulimia nervosa can normally be managed on an outpatient basis. However, there are circumstances when it is necessary to admit the patient for treatment. These include depression too severe to be dealt with in outpatients, deterioration in the physical health of the patient due to the bingeing and purging cycle and the first trimester of pregnancy. Spontaneous abortion is more likely to occur at this time so careful monitoring of mother and baby may be necessary. Inpatient treatment may be required if outpatient management has proved ineffective.

General practitioners' management of a patient with bulimia nervosa will largely be the same as that of the psychiatrist in his/her outpatients. Management can generally be divided into physical, psychological and social:
Physical treatments include the use of antidepressant agents. It has been found that use of antidepressant agents is followed by a reduction in the frequency of overeating and self-induced vomiting, accompanied by an enhanced sense of control over eating. Fluoxetine (Prozac), one of the serotonin re-uptake inhibitors (SSRIs), has been found to be particularly effective. Advice should also be sought from the dietitian, who can educate the patient on nutrition and the need for a balanced diet.
Psychological treatments include the use of cognitive behavioural therapy, where diary keeping and self monitoring are encouraged. Cognitive behavioural therapy aims to improve impulse control and negative self-concept. It has been found to improve attitudes to weight and shape. Group psychotherapy is also used where sufferers can give each other mutual support. Family therapy is recommended if it seems that family dynamics are a component which may be contributing to the illness.
Social factors which need considering are primarily aimed at reducing the isolation that patients experience as a result of the secretive nature of their illness. Helping to re-establish their social environment, collegiate activities and family relationships all help to improve self-esteem. Encouraging them to start new activities and meet new people improves their social skills as well as providing a means of distraction from preoccupation with their eating habits.

Outcome

Not much is known about the course of bulimia nervosa. Some community-based studies have been carried out which suggest that many cases are transitory or resolve on their own. This is in contrast to what is found in clinical practice. Often, it is found that bulimia nervosa is enduring and difficult to treat and generally only those suffering with it chronically present for treatment.

Conclusion

Bulimia nervosa is becoming more common but remains under-diagnosed due to the secretive nature of the illness and the reluctance of sufferers to come forward and seek help. Those in the health profession and those working in schools and further education establishments need to be made aware of the illness. Education on how to identify the illness and how to approach the patient, who initially will probably deny that any problem exists, should be encouraged. It would also help if a change in the attitude of society put women under less pressure to conform to their ideal of the 'perfect woman'. Realistic representations of women in the media would prevent women striving to achieve unattainable goals. This could eradicate feelings of dissatisfaction and self-loathing which underpin bulimia nervosa.

Suki Greaves is Senior Registrar in General Adult Psychiatry, Royal London Hospital

Further reading
1 Anderson AC. Males with Eating Disorders, Brunner and Mazel, New York, 1990
2 Carlet DJ. Review of Bulimia Nervosa in Males. Am J Psych 1991; 148:831
3 Am J Psych 1997; 154: 8 pp.1127-32
4 Fairburn CG, Beglin SJ. Studies of the Epidemiology of Bulimia Nervosa Am J Psych 1990; 147:401
5 Fairburn CG, Cooper PJ. Eating Disorders in Hawton, K, Salkovskis P, Kirk J, Clark DM. (eds) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide, Oxford University Press, Oxford, 1989
6 Fairburn CG, Agras, WS, Wilson GT. The research on the treatment of bulimia nervosa : practical theoretical implications in Anderson, G.H. & Kenney, S.H. (eds) The Biology of Feast and Famine: Relevance to Eating Disorders, Academic Press, New York, 1992
7 Fairburn CG, Jones R, Pereller R. (1991) Three Psychological Treatments for Bulimia Nervosa. Archive General Psych 1991; 48, 463