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Bulimia nervosa

Bulimia nervosa, more commonly known as bulimia, is an eating disorder. It is a psychological condition in which the subject engages in recurrent binge eating followed by intentionally doing one or more of the following in order to compensate for the intake of the food and prevent weight gain: more...

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  • vomiting,
  • inappropriate use of laxatives, enemas, diuretics or other medication,
  • excessive exercising,

The five DSM-IV critera

The following five criteria must all be met for a patient to be diagnosed with bulimia:

  • 1) The patient feels incapable of controlling the urge to binge, even during the binge itself; and he or she consumes a larger amount of food than a person would normally consume at one sitting
  • 2) The patient purges him or herself of the recent intake, resorting to vomiting, laxatives, diuretics, exercising, etc.
  • 3) The patient engages in such behavior occurs at least twice per week for three months.
  • 4) The patient is focused upon body image and the desperate desire to appear thin.
  • 5) The patient does not meet the diagnostic criteria for anorexia nervosa. (Some anorectics may demonstrate bulimic behaviours in their illness: binge-eating and purging themselves of food on a regular or infrequent basis at certain times during the course of their disease. Alternatively, some individuals might switch from having anorexia to having bulimia. The mortality rate for anorectics who practice bulimic behaviors is twice that of anorectics who do not. )
  • 6) The patient is of normal weight or overweight.

Please note that these diagnosis criteria are only a guide, and many doctors will diagnose bulimia nervosa if only one is not present.


Bulimia is often less about food, and more to do with deep psychological issues and profound feelings of lack of control. Binge/purge episodes can be severe, sometimes involving rapid and out of control feeding that can stop when the sufferers "are interrupted by another person . . . or their stomach hurts from over-extension . . . This cycle may be repeated several times a week or, in serious cases, several times a day." Sufferers can often "use the destructive eating pattern to gain control over their lives".

Patterns of bulimic cycles

The frequency of bulimic cycles will vary from person to person. Some will suffer from an episode every few months while others who are more severely ill may binge and purge several times a day. Some people may vomit automatically after they have eaten any food. Others will eat socially but may be bulimic in private. Some people do not regard their illness as a problem, while others despise and fear the vicious and uncontrollable cycle they are in.

Consequences of bulimia nervosa

  • Electrolyte imbalance, heart arrhythmia, heart failure
  • Teeth erosion and cavities
  • Sialadenosis (salivary gland swelling)
  • Potential for gastric rupture during periods of bingeing
  • Acid Reflux
  • Irritation, inflammation, and possible rupture of the esophagus
  • Laxative dependence
  • Peptic ulcers and pancreatitis
  • Emetic toxicity due to ipecac abuse
  • Potentially death


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Metabolic abnormalities in bulimia nervosa - Tips from Other Journals
From American Family Physician, 3/15/04 by Bill Zepf

Persons with anorexia nervosa eventually become visibly recognizable because of their severely underweight status. In contrast, those affected by bulimia are typically of normal weight and are not as easily detected. This disorder is characterized by binge eating and purging. Mehler reviews the diagnosis and treatment of bulimia, using a hypothetical case of a 20-year-old woman noted to have severe hypokalemia and metabolic alkalosis.

Bulimia is most common in late adolescent females. Comorbidity with other psychiatric disorders is typical, and patients with a concomitant personality disorder (e.g., borderline, narcissistic, and antisocial disorders) have a worse prognosis. Although most bulimics purge by vomiting, abuse of laxatives or diuretics also occurs. The number of times a bulimic patient purges can vary widely, from as seldom as once or twice weekly to as often as 10 times per day.

The medical complications of bulimia relate to the method and frequency of purging. Repeatedly induced vomiting can lead to the loss of dental enamel, increased dental caries, swollen salivary glands, Mallory-Weiss esophageal tears, and gastroesophageal reflux. Laxative abusers can develop severe constipation on withdrawal of laxatives, related to damage to the myenteric plexus. The typical electrolyte abnormalities associated with bulimia are hypokalemia and metabolic acidosis. Different purging methods result in different constellations of serum and urine electrolyte disturbances (see accompanying table). The author notes that although severe hypokalemia in an otherwise healthy young female specifically suggests bulimia, most patients who purge do not develop electrolyte abnormalities. Therefore, screening for hypokalemia or other electrolyte derangements is not a sensitive means for detecting purging.

Treatment of the medical complications associated with bulimia is usually possible, but the underlying disorder can be challenging to manage. Fluoridated mouthwash and toothpaste can help ameliorate dental caries, and the use of sour candies may decrease salivary gland swelling. Antacid medications help reduce reflux symptoms, and nonstimulant laxatives may be used to decrease constipation in those with previous stimulant laxative abuse. Oral repletion of low potassium is typically accomplished with 40 to 80 mEq per day of supplementary potassium, until a normal serum potassium level is achieved. Patients with severe hypokalemia and metabolic alkalosis need volume repletion with intravenous normal saline to turn off the renin-angiotensin-aldosterone system and allow normalization of potassium levels.

Cognitive-behavioral therapy has demonstrated efficacy in the treatment of bulimia, but more than 60 percent of patients in one follow-up survey cited by the author still had residual eating disorder features six years after treatment. Disturbances in serotonergic systems have been postulated as contributing to bulimia. The selective serotonin reuptake inhibitor fluoxetine is the only medication that has been approved by the U.S. Food and Drug Administration for treatment of bulimia. Higher dosages of fluoxetine, up to 60 mg daily, may be necessary for effective control. Even with a combination of psychotherapy and pharmacologic treatment, remission rates in studies of bulimic patients averaged less than 50 percent.

Mehler PS. Bulimia nervosa. N Engl J Med August 28, 2003;349:875-81.

COPYRIGHT 2004 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group

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