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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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Antinausea Drug Promising in Treatment of Bulimia Nervosa - Brief Article
From American Family Physician, 9/1/00 by Anne D. Walling

Up to 3 percent of young women have bulimia nervosa as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). The disorder usually includes binge eating followed by self-induced vomiting and incorporates a sense of loss of control over the behavior and distortions of body image. The condition tends to become chronic, and 20 to 50 percent of patients have symptoms for at least five years despite treatment.

Faris and colleagues postulated that afferent vagal circuits could play a role in bulimia because the latter are essential to normal appreciation of satiety and control of pain thresholds. They studied the effect of treating bulimia nervosa with ondansetron, a selective serotonin receptor antagonist. Ondansetron was developed to control vomiting associated with chemotherapy and radiation therapy. The drug acts to decrease afferent vagal neurotransmission.

The investigators selected women who met diagnostic criteria for bulimia nervosa and reported more than seven episodes of binge eating per week and vomiting for at least six months plus loss of control over the behavior. The mean age of the patients was 29 years, and the mean duration of illness was 11.8 years. Most of the patients reported multiple unsuccessful previous attempts at treatment.

The extensive initial assessment included physical and psychological examinations, including testing for depression. The patients selected for the study had a normal physical examination, electrocardiogram and blood count. They had a body mass index of 17.5 to 23.5 kg per m2 (38 lb, 8 oz to 51 lb, 11 oz per m2), and they were not pregnant and did not have any serious medical conditions. Patients were not psychotic, bipolar or suicidal. They had no known history of drug or alcohol abuse, and they were not taking any psychoactive medications.

During the first week of the study, the 26 women recorded all eating behaviors to establish a baseline. In the second week, all patients received placebo tablets but were told that assignment to placebo or active treatment had taken place and that their assignment could be changed from week to week. Beginning in the third week, the patients were randomly assigned to receive ondansetron (14 patients) or an identical-looking placebo capsule (12 patients) for four weeks.

Throughout the study period, the patients maintained a diary of all eating and purging events, other symptoms and medication use (i.e., the times when the study drug or placebo were taken). Daily contact was maintained with a research assistant, and patients were seen each week by a psychiatrist. Weight, height and pill counts were measured at the weekly visits.

Of the ondansetron group, 13 patients completed the study (one patient dropped out because of accidental injury). All 12 patients using placebo completed the study.

During the placebo week, all patients showed a 20 to 23 percent reduction in episodes of bingeing and vomiting behaviors. After four weeks of treatment, the mean number of bingeing and vomiting episodes in the ondansetron group had dropped from 12.8 (placebo week) to 6.5 per week. In the placebo group, the mean number of episodes was 13.4 during the first week and 13.2 after four weeks. Patients in the ondansetron group also showed a significant improvement in the number of normal meals consumed and a significant decrease in the time spent in bulimic practices. Patients treated with ondansetron reported an average decrease of 7.6 hours per week in time spent in bulimic behaviors, compared with an average decrease of 2.3 hours in the placebo group.

The authors concluded that ondansetron appeared to normalize several aspects of satiation and control of eating behaviors.

EDITOR'S NOTE: The toll of bulimia nervosa on patients and their families can be enormous. Because these patients are often of normal weight or only moderately obese, the diagnosis may be missed, or patients may not be believed when they ask for help. Once the problem is recognized, the available treatment strategies are limited and offer only modest success.

This study may open up a new area of therapy, but medication alone is never likely to be successful in patients with bulimia. Patients need a multifaceted approach to develop a healthy concept of food, relearn appropriate eating practices and achieve appropriate self-image and self-esteem. In this process, medication can be a powerful adjunctive treatment.

The results obtained in this study were modest. Even the successful patients continued to invest significant time and energy in abnormal behaviors related to food. Nevertheless, the results are encouraging in that they indicate a possible new line of treatment and verify a physiologic component to this distressing condition. For many patients, knowing that bulimia nervosa is not a completely psychologic condition can be a relief and an incentive to persevere with all aspects of treatment.--A.D.W.

COPYRIGHT 2000 American Academy of Family Physicians
COPYRIGHT 2000 Gale Group

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