Bulimia

What is Bulimia?

Bulimia nervosa is a disorder most commonly found in teenage girls. It’s marked by overeating, or binge-eating, and then using unhealthy methods to avoid gaining weight. The official guide for mental health professionals, known as the Diagnostic and Statistical Manual of Mental Disorders- 5th edition (DSM-V), describes bulimia nervosa as follows:

Times of binge eating, where:

• People eat much larger amounts of food than most would usually eat in a similar time frame (usually less than 2 hours) and in similar circumstances.
• During these eating periods, the person can’t control their eating and eats more than they planned.

These binge-eating episodes are then followed by unhealthy methods to avoid gaining weight such as:

• Making oneself vomit
• Overusing laxatives
• Using water pills or diuretics
• Excessive workouts
• Not eating or fasting

The diagnosis requires these episodes to happen at least once a week for three months.

What Causes Bulimia?

The exact cause of bulimia nervosa isn’t certain but is thought to involve many factors. Changes in the part of the brain that regulates the body’s internal physical state, particularly an area called the insula, could play a role in the excessive eating, or “binging”, linked with this condition.

A study in 2016 found that people with anorexia and bulimia nervosa show wide-ranging changes in the brain’s white matter, which is involved in connecting different brain regions. These changes were particularly noticeable in areas of the brain that control appetite and the reward we get from tasting food.

Other research has suggested that the way the brain functions naturally may be different in people with bulimia nervosa.

Risk Factors and Frequency for Bulimia

Bulimia nervosa is a condition that can affect anyone, but it’s more common in females. It typically starts around the age of 12.4 years. In the United States, we see this condition in about 0.9% of teenagers, 1.5% of women, and 0.5% of men. While we don’t know a lot about how many people have bulimia in countries that are still developing, studies from North America, Australia, and Europe suggest that up to 1.3% of men and up to 2% of women might have it.

• Bulimia nervosa can affect anyone, but tends to more commonly impact females.
• The condition usually begins around age 12.4.
• In the US, it affects about 0.9% of teenagers, 1.5% of women, and 0.5% of men.
• The prevalence of bulimia in developing countries is unclear.
• In North America, Australia, and Europe, up to 1.3% of men and 2% of women could have it.

Signs and Symptoms of Bulimia

Bulimia nervosa is a disorder that involves binge eating episodes followed by behaviors to prevent weight gain. People who are suffering from bulimia nervosa might have symptoms like a sore throat, irregular menstrual cycles, constipation, headaches, fatigue, tiredness, abdominal pain, and bloating.

During a check-up, doctors may take your height and weight, check your vital signs like heart rate and blood pressure, and perform a test called an orthostatic blood pressure test, in which they check how your blood pressure changes when you move from lying down to standing up. They’ll also take a look at your skin, mouth, and belly, and they might do a neurological exam to see if there’s any brain-related reason for weight loss or vomiting.

Bulimia nervosa can also show some physical signs like low blood pressure, dry skin, swelling in the glands near your jaw, tooth decay, and calluses on the back of the hand, which is also known as “Russel’s sign.” Sometimes, people with this disorder might also experience hair loss, swelling in the body, or nosebleeds.

• Sore throat
• Irregular menstrual cycles
• Constipation
• Headaches
• Fatigue
• Tiredness
• Abdominal pain
• Bloating
• Low blood pressure
• Dry skin
• Swelling in the glands near your jaw
• Tooth decay
• Calluses on the back of the hand (Russel’s sign)
• Hair loss
• Swelling in the body
• Nosebleeds

Testing for Bulimia

If you are being checked for bulimia nervosa, your doctor might need to perform several tests. These include a comprehensive metabolic panel, which looks at your electrolyte levels, how well your liver is working, your blood urea nitrogen levels, serum creatinine, and calcium. They may also perform a complete blood count and possibly check your vitamin B12 level. They might also ask for a urine test.

If the condition seems severe, they might test your serum magnesium and phosphorous levels and take an electrocardiogram, which is a test that looks at the electrical activity of your heart. If you’re a woman, your doctor may request a pregnancy test. If you’ve stopped having your period, they might test for luteinizing hormone, prolactin, beta-HCG, and follicle-stimulating hormone. These hormones can help them figure out if there’s another reason why you’ve stopped having your period.

Although it’s possible to test for certain laxatives in stool or urine, such as bisacodyl, emodin, aloe-emodin, and rhein, a positive test result isn’t needed to diagnose bulimia nervosa.

Results from these tests might show abnormalities associated with bulimia nervosa. These include low levels of potassium (sometimes along with low levels of chloride and a condition known as metabolic alkalosis), low levels of sodium, and transaminitis, a condition that indicates damage to the liver.

Treatment Options for Bulimia

The main goal in treating bulimia nervosa is to stop the pattern of binge eating and purging. Some antidepressants, like fluoxetine, citalopram, and sertraline, can ease the symptoms of this condition. Fluoxetine is the only medication specifically approved by the FDA for treating bulimia. The research shows that a higher dose of this drug can significantly reduce binge-eating and vomiting episodes. There’s limited evidence to support the use of other types of medication for this condition.

One medication named Trazodone has been found to effectively reduce binge-eating episodes. However, medications known as Monoamine oxidase inhibitors and tricyclic antidepressants are generally used only for serious cases due to the risks and potential side effects. It’s recommended not to use a drug called Bupropion, as it raises the risk of having an epileptic episode. Another medication, Topiramate, previously used for epilepsy, also reduces binge episodes, but its side effects must be monitored closely, particularly weight loss and cognitive issues.

Therapy methods such as cognitive-behavioral therapy and interpersonal psychotherapy also have proven benefits for people with bulimia. It’s crucial for people with bulimia to get screened for suicidal tendencies and other psychiatric illnesses, because they have a higher risk of developing these.

Bulimia nervosa can cause many health complications, including an imbalance of chemicals in the body (metabolic alkalosis), dehydration, constipation, and irregular heartbeats. Fluid volume depletion often causes metabolic alkalosis in those with bulimia, and treatment involves administering saline along with stopping the purging behavior. For hospitalized patients, administer fluid directly into their veins but watch out for signs of excess fluid.

The treatment for dehydration associated with bulimia is similar. In rare cases, where a bulimic patient’s fluid volume is normal or increased yet they still have metabolic alkalosis, intravenous saline is not needed. Constipation caused by bulimia or by stopping laxatives can be treated with adequate hydration, exercise, and dietary fiber. If laxatives are still needed, small doses of polyethylene glycol powder or lactulose may be used. In the case of severe heart complications caused by bulimia, usually due to chemical imbalance, considering a consultation with a heart specialist or cardiologist might be warranted.

What else can Bulimia be?

Before a doctor diagnoses bulimia nervosa, which is characterized by episodes of bingeing and purging, other medical causes causing vomiting and excessive bowel movement need to be ruled out. If a patient has bulimia nervosa, they often describe bingeing or purging as a behavior that they can’t control.

• Biliary disease can result in sickness and vomiting, usually presenting with abnormal results in a metabolic profile.
• Irritable bowel syndrome may lead to an increased number of bowel movements, but it doesn’t typically involve binge eating.
• With certain neurological conditions, vomiting can be a symptom. A neurological exam can help identify these conditions.

There are also several conditions which result in an increased appetite:

• Prader-Willi syndrome is a genetic disorder which can cause overeating and obesity, along with mental disabilities and hormonal imbalances. Aggressive behavior and a refusal to follow rules are also common. However, purging behaviour to compensate for overeating is not usually observed.
• Klein-Levin syndrome, commonly found in teenage boys, can cause increased appetite, excessive sleep, and behavioral problems. Just like Prader-Willi syndrome, purging behavior is not present in this condition.
• Diabetes is a famous cause of overeating. Blood glucose levels should be checked during a medical evaluation.

It’s important to distinguish between anorexia nervosa and bulimia nervosa as the complications, treatments, and outcomes differ significantly. In anorexia nervosa, if any binging or purging happens, it only happens during episodes of anorexia nervosa. A key aspect is that anorexia nervosa diagnosis requires a low body weight, whereas that’s not a requirement for diagnosing bulimia nervosa. Medicine targeted at mental health has been shown to have limited benefits for treating anorexia nervosa.

Binge eating disorder is another condition which is characterized by overeating, but it does not include the purging behavior seen in bulimia nervosa. People with bulimia nervosa commonly limit their eating between binges in an attempt to control their body shape, unlike those with a binge eating disorder who do not restrict their eating.

Major depressive disorder and borderline personality disorder can both present with overeating and thoughts of suicide. However, neither of these conditions involve the harmful purging behavior seen in bulimia nervosa. But, it’s worth noting that these conditions can happen at the same time as bulimia nervosa.

What to expect with Bulimia

Most people who suffer from bulimia nervosa eventually recover from the disorder.

According to statistics using the DSM-IV criteria, around 74% of patients experience remission from bulimia nervosa within a five-year period. However, about 47% of the patients within this group also suffer a relapse during those five years. Another study, using the more recent DSM-V criteria, showed a 55% recovery rate from bulimia nervosa within five years in the general population. Additionally, after ten years, 52% of patients with bulimia nervosa given a placebo had completely recovered.

It’s important to note that bulimia nervosa is associated with a higher risk of mortality from all causes.

Possible Complications When Diagnosed with Bulimia

Bulimia nervosa is a mental health disorder that can lead to serious complications. In contrast to anorexia nervosa, where complications arise due to weight loss and undernutrition, the type and severity of medical complications of bulimia depend on the frequency and method of purging used by the patient.

The following are the potential complications associated with bulimia nervosa:

• Salivary gland enlargement and swollen cheeks: This often affects the parotid gland but can also target the submandibular salivary gland causing swelling.
• Mallory-Weiss syndrome: This refers to tears in the esophagus near the stomach junction. They can occur due to heavy stomach contractions during vomiting and may develop into a severe condition known as Boerhaave’s syndrome (esophageal rupture).
• Gastroesophageal reflux disease (GERD): GERD can lead to a condition called Barrett’s esophagus. In Barrett’s esophagus, normal tissue lining the esophagus changes to tissue resembling the lining of the intestine. This might increase the risk of developing esophageal cancer.
• Laryngopharyngeal reflux: Symptoms include coughing, hoarse voice, sore throat, and swallowing difficulties.
• Irritable bowel syndrome (IBS): A study found out that approximately 69% of patients with bulimia nervosa also have IBS.
• Achalasia: This is the failure of lower esophageal muscles to relax.
• Esophageal spasm: Irregular contractility of esophageal muscles.
• Cardiac arrhythmia: Can occur due to low potassium levels from self-induced vomiting. Hypokalemia can contribute to a long QT syndrome.
• Constipation: Chronic abuse of laxatives can lead to a condition called cathartic colon syndrome.
• Dental enamel erosion: This can occur due to gastric acid washing over teeth and may lead to gum recession.
• Rectal prolapse: Rare cases have been reported in women with bulimia nervosa, possibly due to constipation or increased pressure associated with vomiting.
• Recurrent acute pancreatitis: Though not fully understood, bulimia nervosa has been linked with recurrent episodes of pancreatitis.
• Diabetes: Bulimia nervosa is also associated with an increased risk of developing type 2 diabetes.

Preventing Bulimia

It’s very essential for those using laxatives excessively to know that these drugs take effect in parts of the digestive system where most of the calorie absorption has already happened. It’s also important to make them aware that swelling and weight gain can occur for several weeks after they stop the habit of purging.

Moreover, individuals dealing with bulimia nervosa, who purge by throwing up usually brush their teeth right after the act. This habit can lead to faster tooth wear and tear. If these people continue to vomit, they should rinse their mouths with water or a fluoride rinse instead of brushing their teeth for at least 30 minutes after each episode. Finally, it may be helpful to seek advice from a dentist to address any dental problems that may arise as a side effect of vomiting.