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Bulimia nervosa, also known simply as bulimia, is an
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's health, physical or mental health, mental health. These behaviors may include eating too much food or too little food. Types of eatin ...
characterized by
binge eating Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an exc ...
(eating large quantities of food in a short period of time, often feeling out of control) followed by compensatory behaviors, such as self-induced vomiting or fasting, to prevent weight gain. Other efforts to lose weight may include the use of
diuretics A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics in ...
,
laxatives Laxatives, purgatives, or aperients are substances that loosen human feces, stools and increase defecation, bowel movements. They are used to treat and prevent constipation. Laxatives vary as to how they work and the side effects they may have. ...
,
stimulant Stimulants (also known as central nervous system stimulants, or psychostimulants, or colloquially as uppers) are a class of drugs that increase alertness. They are used for various purposes, such as enhancing attention, motivation, cognition, ...
s,
water fasting Fasting is the act of refraining from eating, and sometimes drinking. However, from a purely physiological context, "fasting" may refer to the metabolic status of a person who has not eaten overnight (before "breakfast"), or to the metabolic state ...
, or excessive exercise. Most people with bulimia are at normal weight and have higher risk for other mental disorders, such as depression, anxiety, borderline personality disorder, bipolar disorder, and problems with drugs to alcohol. There is also a higher risk of suicide and self-harm. Bulimia is more common among those who have a close relative with the condition. The percentage risk that is estimated to be due to genetics is between 30% and 80%. Other risk factors for the disease include
psychological stress In psychology, stress is a feeling of emotional strain and pressure. Stress is a form of psychological and mental discomfort. Small amounts of stress may be beneficial, as it can improve athletic performance, motivation and reaction to the envi ...
, cultural pressure to attain a certain body type, poor self-esteem, and
obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...
. Living in a culture that commercializes or glamorizes
dieting Dieting is the practice of eating food in a regulated way to decrease, maintain, or increase body weight, or to prevent and treat diseases such as diabetes and obesity. As weight loss depends on calorie intake, List of diets, different kinds of ...
, and having parental figures who fixate on weight are also risks. Diagnosis is based on a person's medical history; however, this is difficult, as people are usually secretive about their binge eating and purging habits. Further, the diagnosis of
anorexia nervosa Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
takes precedence over that of bulimia. Other similar disorders include
binge eating disorder Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
, Kleine–Levin syndrome, and
borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
.

Signs and symptoms

Bulimia typically involves rapid and out-of-control eating, which is followed by self-induced vomiting or other forms of purging. This cycle may be repeated several times a week or, in more serious cases, several times a day and may directly cause: *
Dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...
*
Electrolyte imbalance Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function ...
can lead to abnormal heart rhythms,
cardiac arrest Cardiac arrest (also known as sudden cardiac arrest CA is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly Circulatory system, circulate around the body and the blood flow to the ...
, and even death * Oral trauma, lacerations to the lining of the mouth or throat due to forced throwing up movements. *
Russell's sign Russell's sign, named after British psychiatrist Gerald Russell, is a sign defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time. The condition generally arises from the patient's k ...
:
callus A callus (: calluses) is an area of thickened and sometimes hardened skin that forms as a response to repeated friction, pressure, or other irritation. Since repeated contact is required, calluses are most often found on the feet and hands, b ...
es on knuckles and back of hands due to repeated trauma from incisors * Swollen
salivary gland The salivary glands in many vertebrates including mammals are exocrine glands that produce saliva through a system of ducts. Humans have three paired major salivary glands ( parotid, submandibular, and sublingual), as well as hundreds of min ...
s (in the neck, under the jawline) * Gastrointestinal problems, like constipation and acid reflux *
Constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the ...
or
diarrhea Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...
*
Hypotension Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...
*
Infertility In biology, infertility is the inability of a male and female organism to Sexual reproduction, reproduce. It is usually not the natural state of a healthy organism that has reached sexual maturity, so children who have not undergone puberty, whi ...
and/or irregular menstrual cycles * Weight Fluctuations These are some of the many signs that may indicate whether someone has bulimia nervosa: * A fixation on the number of calories consumed * A fixation on an extreme consciousness of one's weight * Low self-esteem and/or
self-harm Self-harm refers to intentional behaviors that cause harm to oneself. This is most commonly regarded as direct injury of one's own skin tissues, usually without suicidal intention. Other terms such as cutting, self-abuse, self-injury, and s ...
*
Suicidal Suicide is the act of intentionally causing one's own death. Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or acad ...
tendencies * An irregular menstrual cycle in women * Regular trips to the bathroom, especially soon after eating * Depression,
anxiety disorders Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...
, and
sleep disorders A sleep disorder, or somnipathy, is a medical disorder affecting an individual's sleep patterns, sometimes impacting physical, mental, social, and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing sle ...
* Frequent occurrences involving the consumption of abnormally large portions of food * The use of
laxatives Laxatives, purgatives, or aperients are substances that loosen human feces, stools and increase defecation, bowel movements. They are used to treat and prevent constipation. Laxatives vary as to how they work and the side effects they may have. ...
,
diuretic A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics ...
s, and
diet pills Anti-obesity medication or weight loss medications are pharmacological agents that reduce or control excess body fat. These medications alter one of the fundamental processes of the human anatomy, human body, body weight, weight regulation, by ...
* Compulsive or excessive exercise * Unhealthy/dry skin, hair, nails, and lips *
Fatigue Fatigue is a state of tiredness (which is not sleepiness), exhaustion or loss of energy. It is a signs and symptoms, symptom of any of various diseases; it is not a disease in itself. Fatigue (in the medical sense) is sometimes associated wit ...
, or exhaustion As with many psychiatric illnesses, side effects such as delusions can occur, in conjunction with other signs and symptoms, leaving the person with a false belief that is not ordinarily accepted by others. People with bulimia nervosa may also exercise to a point that excludes other activities.


Interoceptive

People with bulimia exhibit several
interoceptive Interoception is the collection of senses providing information to the organism about the internal state of the body. This can be both conscious and subconscious. It encompasses the brain's process of integrating signals relayed from the body int ...
deficits, in which one experiences impairment in recognizing and discriminating between internal sensations, feelings, and emotions. People with bulimia may also react negatively to somatic and
affective Affect, in psychology, is the underlying experience of feeling, emotion, attachment, or mood. It encompasses a wide range of emotional states and can be positive (e.g., happiness, joy, excitement) or negative (e.g., sadness, anger, fear, dis ...
states. Regarding interoceptive sensation, hyposensitive individuals may not detect normal feelings of fullness at the appropriate time while eating, and are prone to eating more calories in a short period of time as a result of this decreased sensitivity. Examining from a neural basis also connects elements of interoception and emotion; notable overlaps occur in the medial
prefrontal cortex In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. It is the association cortex in the frontal lobe. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, ...
, anterior and posterior cingulate, and anterior insula cortices, which are linked to both interoception and emotional eating.


Related disorders

People with bulimia are at a higher risk to have an affective disorder, such as depression or general anxiety disorder. One study found 70% had depression at some time in their lives (as opposed to 26% for adult females in the general population), rising to 88% for all affective disorders combined. Another study in the Journal of Affective Disorders found that of the population of patients that were diagnosed with an eating disorder according to the DSM-V guidelines about 27% also suffered from bipolar disorder. Within this article, the majority of the patients were diagnosed with bulimia nervosa, the second most common condition reported was binge-eating disorder. Some individuals with anorexia nervosa exhibit episodes of bulimic tendencies through purging (either through self-induced vomiting or laxatives) as a way to quickly remove food in their system. There may be an increased risk for
diabetes mellitus type 2 Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent ...
. Bulimia also has negative effects on a person's teeth due to the acid passed through the mouth from frequent vomiting causing acid erosion, mainly on the posterior dental surface. Research has shown that there is a relationship between bulimia and
narcissism Narcissism is a self-centered personality style characterized as having an excessive preoccupation with oneself and one's own needs, often at the expense of others. Narcissism, named after the Greek mythological figure ''Narcissus'', has evolv ...
. According to a study by the
Australian National University The Australian National University (ANU) is a public university, public research university and member of the Group of Eight (Australian universities), Group of Eight, located in Canberra, the capital of Australia. Its main campus in Acton, A ...
, eating disorders are more susceptible among vulnerable narcissists. This can be caused by a childhood in which inner feelings and thoughts were minimized by parents, leading to "a high focus on receiving validation from others to maintain a positive sense of self". * The medical journal ''Borderline Personality Disorder and Emotion Dysregulation'' notes that a "substantial rate of patients with bulimia nervosa" also have
borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
. A study by the Psychopharmacology Research Program of the
University of Cincinnati College of Medicine University of Cincinnati Health (UC Health) is the healthcare system of the University of Cincinnati, Cincinnati, Ohio. It trains health care professionals and provides research and patient care. The system is affiliated with the University via ...
"leaves little doubt that bipolar and eating disorders—particularly bulimia nervosa and bipolar II disorder—are related." The research shows that most clinical studies indicate that patients with bipolar disorder have higher rates of eating disorders, and vice versa. There is overlap in phenomenology, course, comorbidity, family history, and pharmacologic treatment response of these disorders. This is especially true of "eating dysregulation, mood dysregulation, impulsivity and compulsivity, craving for activity and/or exercise." Studies have shown a relationship between bulimia's effect on metabolic rate and caloric intake with thyroid dysfunction. Scientific research has shown that people suffering from bulimia have decreased volumes of brain matter, and that the abnormalities are reversible after long-term recovery.


Causes


Biological

As with
anorexia nervosa Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
, there is evidence of genetic predispositions contributing to the onset of this eating disorder. Abnormal levels of many hormones, notably
serotonin Serotonin (), also known as 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter with a wide range of functions in both the central nervous system (CNS) and also peripheral tissues. It is involved in mood, cognition, reward, learning, ...
, have been shown to be responsible for some disordered eating behaviors.
Brain-derived neurotrophic factor Brain-derived neurotrophic factor (BDNF), or abrineurin, is a protein found in the and the periphery. that, in humans, is encoded by the ''BDNF'' gene. BDNF is a member of the neurotrophin family of growth factors, which are related to the can ...
(BDNF) is under investigation as a possible mechanism. There is evidence that sex hormones may influence appetite and eating in women and the onset of bulimia nervosa. Studies have shown that women with
hyperandrogenism Hyperandrogenism is a medical condition characterized by high levels of androgens. It is more common in women than men. Symptoms of hyperandrogenism may include acne, seborrhea, hair loss on the scalp, increased body or facial hair, and infre ...
and
polycystic ovary syndrome Polycystic ovary syndrome, or polycystic ovarian syndrome, (PCOS) is the most common endocrine disorder in women of reproductive age. The name is a misnomer, as not all women with this condition develop cysts on their ovaries. The name origin ...
have a dysregulation of appetite, along with carbohydrates and fats. This dysregulation of appetite is also seen in women with bulimia nervosa. There is evidence that there is an association between polymorphisms in the ERβ (
estrogen receptor Estrogen receptors (ERs) are proteins found in cell (biology), cells that function as receptor (biochemistry), receptors for the hormone estrogen (17β-estradiol). There are two main classes of ERs. The first includes the intracellular estrogen ...
β) and bulimia, suggesting there is a correlation between sex hormones and bulimia nervosa. Bulimia has been compared to drug addiction, though the empirical support for this characterization is limited. However, people with bulimia nervosa may share dopamine D2 receptor-related vulnerabilities with those with
substance use disorder Substance use disorder (SUD) is the persistent use of drugs despite substantial harm and adverse consequences to self and others. Related terms include ''substance use problems'' and ''problematic drug or alcohol use''. Along with substance-ind ...
s. Dieting, a common behaviour in bulimics, is associated with lower plasma tryptophan levels. Decreased tryptophan levels in the brain, and thus the synthesis of serotonin, such as via
acute tryptophan depletion Acute tryptophan depletion (ATD) is a technique used extensively to study the effect of low serotonin in the brain. This experimental approach reduces the availability of tryptophan, an amino acid Amino acids are organic compounds that conta ...
, increases bulimic urges in currently and formerly bulimic individuals within hours. Abnormal blood levels of peptides important for the regulation of appetite and energy balance are observed in individuals with bulimia nervosa, but it remains unknown if this is a state or trait. In recent years,
evolutionary psychiatry Evolutionary psychiatry, also known as Darwinian Psychiatry, is a theoretical approach to psychiatry that aims to explain psychiatric disorders in evolutionary terms. As a branch of the field of evolutionary medicine, it is distinct from the medic ...
as an emerging scientific discipline has been studying
mental disorder A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...
s from an evolutionary perspective. If eating disorders, Bulimia nervosa in particular, have evolutionary functions or if they are new modern "lifestyle" problems is still debated.


Social

Media portrayals of an 'ideal' body shape are widely considered to be a contributing factor to bulimia. In a 1991 study by Weltzin, Hsu, Pollicle, and Kaye, it was stated that 19% of bulimics undereat, 37% of bulimics eat an average or normal amount of food, and 44% of bulimics overeat. A survey of 15- to 18-year-old high school girls in Nadroga,
Fiji Fiji, officially the Republic of Fiji, is an island country in Melanesia, part of Oceania in the South Pacific Ocean. It lies about north-northeast of New Zealand. Fiji consists of an archipelago of more than 330 islands—of which about ...
, found the self-reported incidence of purging rose from 0% in 1995 (a few weeks after the introduction of television in the province) to 11.3% in 1998. In addition, the suicide rate among people with bulimia nervosa is 7.5 times higher than in the general population. When attempting to decipher the origin of bulimia nervosa in a cognitive context, Christopher Fairburn ''et al.''s cognitive-behavioral model is often considered the golden standard. Fairburn et al.'s model discusses the process in which an individual falls into the binge-purge cycle and thus develops bulimia. Fairburn ''et al.'' argue that extreme concern with weight and shape coupled with low self-esteem will result in strict, rigid, and inflexible dietary rules. Accordingly, this would lead to unrealistically restricted eating, which may consequently induce an eventual "slip" where the individual commits a minor infraction of the strict and inflexible dietary rules. Moreover, the cognitive distortion due to
dichotomous A dichotomy () is a partition of a set, partition of a whole (or a set) into two parts (subsets). In other words, this couple of parts must be * jointly exhaustive: everything must belong to one part or the other, and * mutually exclusive: nothi ...
thinking leads the individual to binge. The binge subsequently should trigger a perceived loss of control, promoting the individual to purge in hope of counteracting the binge. However, Fairburn ''et al.'' assert the cycle repeats itself, and thus consider the binge-purge cycle to be self-perpetuating. In contrast, Byrne and Mclean's findings differed slightly from Fairburn ''et al.''s cognitive-behavioral model of bulimia nervosa in that the drive for thinness was the major cause of purging as a way of controlling weight. In turn, Byrne and Mclean argued that this makes the individual vulnerable to binging, indicating that it is not a binge-purge cycle but rather a purge-binge cycle in that purging comes before bingeing. Similarly, Fairburn ''et al.''s cognitive-behavioral model of bulimia nervosa is not necessarily applicable to every individual and is certainly reductionist. Every one differs from another, and taking such a complex behavior like bulimia and applying the same one theory to everyone would certainly be invalid. In addition, the cognitive-behavioral model of bulimia nervosa is very culturally bound in that it may not be necessarily applicable to cultures outside of Western society. To evaluate, Fairburn ''et al.''.'s model and more generally the cognitive explanation of bulimia nervosa is more descriptive than explanatory, as it does not necessarily explain how bulimia arises. Furthermore, it is difficult to ascertain cause and effect, because it may be that distorted eating leads to distorted cognition rather than vice versa. A considerable amount of literature has identified a correlation between sexual abuse and the development of bulimia nervosa. The reported incident rate of unwanted sexual contact is higher among those with bulimia nervosa than anorexia nervosa. When exploring the etiology of bulimia through a socio-cultural perspective, the "thin ideal internalization" is significantly responsible. The thin-ideal internalization is the extent to which individuals adapt to the societal ideals of attractiveness. Studies have shown that young women that read fashion magazines tend to have more bulimic symptoms than those women who do not. This further demonstrates the impact of media on the likelihood of developing the disorder. Individuals first accept and "buy into" the ideals, and then attempt to transform themselves in order to reflect the societal ideals of attractiveness. J. Kevin Thompson and Eric Stice claim that family, peers, and most evidently media reinforce the thin ideal, which may lead to an individual accepting and "buying into" the thin ideal. In turn, Thompson and Stice assert that if the thin ideal is accepted, one could begin to feel uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal set out by society. Thus, people feeling uncomfortable with their bodies may result in body dissatisfaction and may develop a certain drive for thinness. Consequently, body dissatisfaction coupled with a drive for thinness is thought to promote dieting and negative effects, which could eventually lead to bulimic symptoms such as purging or bingeing. Binges lead to self-disgust which causes purging to prevent weight gain. A study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is Thompson's and Stice's research. Their study aimed to investigate how and to what degree media affects the thin ideal internalization. Thompson and Stice used randomized experiments (more specifically programs) dedicated to teaching young women how to be more critical when it comes to media, to reduce thin-ideal internalization. The results showed that by creating more awareness of the media's control of the societal ideal of attractiveness, the thin ideal internalization significantly dropped. In other words, less thin ideal images portrayed by the media resulted in less thin-ideal internalization. Therefore, Thompson and Stice concluded that media greatly affected the thin ideal internalization. Papies showed that it is not the thin ideal itself, but rather the self-association with other persons of a certain weight that decide how someone with bulimia nervosa feels. People that associate themselves with thin models get in a positive attitude when they see thin models and people that associate with overweight get in a negative attitude when they see thin models. Moreover, it can be taught to associate with thinner people.


Diagnosis

The onset of bulimia nervosa is often during adolescence, between 13 and 20 years of age, and many cases have previously experienced obesity, with many relapsing in adulthood into episodic bingeing and purging even after initially successful treatment and remission. A lifetime
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of 0.5 percent and 0.9 percent for adults and adolescents, respectively, is estimated among the United States population. Bulimia nervosa may affect up to 1% of young women and, after 10 years of diagnosis, half will recover fully, a third will recover partially, and 10–20% will still have symptoms. Adolescents with bulimia nervosa are more likely to have self-imposed perfectionism and compulsivity issues in eating compared to their peers. This means that the high expectations and unrealistic goals that these individuals set for themselves are internally motivated rather than by social views or expectations.


Criteria

Bulimia Nervosa is diagnosed using the ''Diagnostic and Statistical Manual of Mental Disorders (DSM-5).'' The diagnostic criteria include the following: * Recurrent episodes of binge eating * Recurrent inappropriate compensatory behavior to prevent weight gain, like self-induced vomiting, misuse of laxatives or other medications, fasting, or excessive exercise. * The binge eating and compensatory behaviors both occur at least once a week for three months * Self-evaluation is influenced by body shape and weight. Other methods are also used to narrow down the diagnosis, such as physical exams (measuring height, weight, and vitals, or checking skin, nails, heart and lungs), or lab tests (for blood count, electrolytes, protein, or urinalysis).


Treatment

There are two main types of treatment given to those with bulimia nervosa; psychopharmacological and psychosocial treatments.


Psychotherapy

Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...
(CBT) is considered the gold standard for the treatment of bulimia nervosa. This approach focuses on helping patients identify and change distorted thought patterns related to eating, body image, and self worth. CBT helps patients identify and challenge the distorted thinking individuals might have about food, weight and body image. It also helps by offering the chance to identify the unhelpful thoughts about food and body image. By using CBT people record how much food they eat and periods of vomiting with the purpose of identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular basis, as a component of this therapy is food journaling. CBT is necessarily good for those with bulimia as it targets the binge-purge cycle, which is the hallmark of bulimia. People undergoing CBT who exhibit early behavioral changes are most likely to achieve the best treatment outcomes in the long run. Researchers have also reported some positive outcomes for
interpersonal psychotherapy Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and achieving symptomatic recovery. IPT is an empirically supported treatment (EST) that follows a highly structured and ...
and
dialectical behavior therapy Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideati ...
. These therapies have good outcomes for treating bulimia, especially in patients with emotional regulation difficulties or interpersonal issues. While these therapies are not as extensively researched as CBT, they can be beneficial when integrated into a comprehensive treatment plan. For adolescents, Family-Based therapy (FBT) has been identified as an effective treatment. FBT involves the family in the treatment process, where parents are empowered to take an active role in helping their child recover from bulimia nervosa. This approach is particularly helpful in younger patients who are still living with their families The use of CBT has been shown to be quite effective for treating bulimia nervosa (BN) in adults, but little research has been done on effective treatments of BN for adolescents. Although CBT is seen as more cost-efficient and helps individuals with BN in self-guided care, Family Based Treatment (FBT) might be more helpful to younger adolescents who need more support and guidance from their families. Adolescents are at the stage where their brains are still quite malleable and developing gradually. Therefore, young adolescents with BN are less likely to realize the detrimental consequences of becoming bulimic and have less motivation to change, which is why FBT would be useful to have families intervene and support the teens. Working with BN patients and their families in FBT can empower the families by having them involved in their adolescent's food choices and behaviors, taking more control of the situation in the beginning and gradually letting the adolescent become more autonomous when they have learned healthier eating habits.


Medication

Antidepressants, particularly
selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs primarily work by blo ...
s (SSRI), are often prescribed to treat bulimia nervosa, especially when comorbid depression or anxiety disorders are present. However, medications alone are generally not sufficient and are typically used in conjunction with psychotherapy. Compared to placebo, the use of a single antidepressant has been shown to be effective. Combining medication with counseling can improve outcomes in some circumstances. Some positive outcomes of treatments can include: abstinence from binge eating, a decrease in obsessive behaviors to lose weight and in shape preoccupation, less severe psychiatric symptoms, a desire to counter the effects of binge eating, as well as an improvement in social functioning and reduced relapse rates. A combination of psychotherapy, especially CBT and pharmacological treatments, such as SSRIs, often lead to better outcomes for individuals with bulimia. Combining both approaches is particularly beneficial in severe or chronic cases, where behavioral modification and mood stabilization are crucial.


Alternative medicine

Some researchers have also claimed positive outcomes in
hypnotherapy Hypnotherapy, also known as hypnotic medicine, is the use of hypnosis in psychotherapy. Hypnotherapy is generally not considered to be based on scientific evidence, and is rarely recommended in clinical practice guidelines. However, several p ...
. ''The first use of hypnotherapy in Bulimic patients was in 1981. When it comes to hypnotherapy, Bulimic patients are easier to hypnotize than Anorexia Nervosa patients. In Bulimic patients, hypnotherapy focuses on learning self-control when it comes to binging and vomiting, strengthening stimulus control techniques, enhancing ones ego, improving weight control, and helping overweight patients see their body differently (have a different image).''


Risk factors

Being female and having bulimia nervosa takes a toll on mental health. Women frequently reported an onset of anxiety at the same time of the onset of bulimia nervosa. The approximate female-to-male ratio of diagnosis is 10:1. In addition to cognitive, genetic, and environmental factors, childhood gastrointestinal problems and early pubertal maturation also increase the likelihood of developing bulimia nervosa. Another concern with eating disorders is developing a coexisting
substance use disorder Substance use disorder (SUD) is the persistent use of drugs despite substantial harm and adverse consequences to self and others. Related terms include ''substance use problems'' and ''problematic drug or alcohol use''. Along with substance-ind ...
.


Epidemiology

There is little data on the percentage of people with bulimia in general populations. Most studies conducted thus far have been on convenience samples from hospital patients, high school or university students; research on bulimia nervosa among ethnic minorities has also been limited. Existing studies have yielded a wide range of results: between 0.1% and 1.4% of males, and between 0.3% and 9.4% of females. Studies on time trends in the prevalence of bulimia nervosa have also yielded inconsistent results. According to Gelder, Mayou and Geddes (2005) bulimia nervosa is prevalent between 1 and 2 percent of women aged 15–40 years. Bulimia nervosa occurs more frequently in developed countries and in cities, with one study finding that bulimia is five times more prevalent in cities than in rural areas. There is a perception that bulimia is most prevalent amongst girls from middle-class families; however, in a 2009 study girls from families in the lowest income bracket studied were 153 percent more likely to be bulimic than girls from the highest income bracket. According to a study conducted in 2022 by Silen et al., which conglomerated statistics using various methods such as SCID, MRFS, EDE, SSAGA, and EDDI, the US, Finland, Australia, and the Netherlands had an estimated 2.1%, 2.4%, 1.0%, and 0.8% prevalence of bulimia nervosa among females under 30 years of age. This demonstrates the prevalence of bulimia nervosa in developed, Western, first-world countries, indicating an urgency in treating adolescent women. Additionally, these statistics may be misrepresentative of the true population affected with bulimia nervosa due to potential underreporting bias. There are higher rates of
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's health, physical or mental health, mental health. These behaviors may include eating too much food or too little food. Types of eatin ...
s in groups involved in activities which idealize a slim physique, such as dance, gymnastics, modeling,
cheerleading Cheerleading is an activity in which the participants (called cheerleaders) cheer for their team as a form of encouragement. It can range from chanting slogans to intense Physical exercise, physical activity. It can be performed to motivate s ...
, running, acting, swimming, diving, rowing and
figure skating Figure skating is a sport in which individuals, pairs, or groups perform on figure skates on ice. It was the first winter sport to be included in the Olympic Games, with its introduction occurring at the Figure skating at the 1908 Summer Olympi ...
. Bulimia is thought to be more prevalent among
whites White is a racial classification of people generally used for those of predominantly European ancestry. It is also a skin color specifier, although the definition can vary depending on context, nationality, ethnicity and point of view. De ...
; however, a more recent study showed that African-American teenage girls were 50 percent more likely than white girls to exhibit bulimic behavior, including both binging and purging.


History


Etymology

The term ''bulimia'' comes from
Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...
''boulīmia'', "ravenous hunger", a compound of βοῦς ''bous'', "ox" and λιμός, ''līmos'', "hunger". Literally, the scientific name of the disorder, ''bulimia nervosa'', translates to "nervous ravenous hunger".


Before the 20th century

Although diagnostic criteria for bulimia nervosa did not appear until 1979, evidence suggests that binging and purging were popular in certain ancient cultures. The first documented account of behavior resembling bulimia nervosa was recorded in Xenophon's Anabasis around 370 B.C, in which Greek soldiers purged themselves in the mountains of
Asia Minor Anatolia (), also known as Asia Minor, is a peninsula in West Asia that makes up the majority of the land area of Turkey. It is the westernmost protrusion of Asia and is geographically bounded by the Mediterranean Sea to the south, the Aegean ...
. It is unclear whether this purging was preceded by binging.Giannini, A. J. (1993). "A history of bulimia". In ''The Eating disorders'' (pp. 18–21). Springer New York. In ancient Egypt, physicians recommended purging once a month for three days to preserve health.Russell, G. (1997). ''The history of bulimia nervosa''. D. Garner & P. Garfinkel (Eds.), Handbook of Treatment for Eating Disorders (2nd ed., pp. 11–24). New York, NY: The Guilford Press. This practice stemmed from the belief that human diseases were caused by the food itself. In ancient Rome, elite society members would vomit to "make room" in their stomachs for more food at all-day banquets. Emperors
Claudius Tiberius Claudius Caesar Augustus Germanicus ( ; ; 1 August 10 BC – 13 October AD 54), or Claudius, was a Roman emperor, ruling from AD 41 to 54. A member of the Julio-Claudian dynasty, Claudius was born to Nero Claudius Drusus, Drusus and Ant ...
and
Vitellius Aulus Vitellius ( ; ; 24 September 1520 December 69) was Roman emperor for eight months, from 19 April to 20 December AD 69. Vitellius became emperor following the quick succession of the previous emperors Galba and Otho, in a year of civil wa ...
both were gluttonous and obese, and they often resorted to habitual purging. Historical records also suggest that some saints who developed
anorexia Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...
(as a result of a life of asceticism) may also have displayed bulimic behaviors. Saint Mary Magdalen de Pazzi (1566–1607) and Saint Veronica Giuliani (1660–1727) were both observed binge eating—giving in, as they believed, to the temptations of the devil. Saint Catherine of Siena (1347–1380) is known to have supplemented her strict abstinence from food by purging as reparation for her sins. Catherine died from starvation at age thirty-three. While the psychological disorder "bulimia nervosa" is relatively new, the word "bulimia", signifying overeating, has been present for centuries. The Babylon
Talmud The Talmud (; ) is the central text of Rabbinic Judaism and the primary source of Jewish religious law (''halakha'') and Jewish theology. Until the advent of Haskalah#Effects, modernity, in nearly all Jewish communities, the Talmud was the cen ...
referenced practices of "bulimia", yet scholars believe that this simply referred to overeating without the purging or the psychological implications bulimia nervosa. In fact, a search for evidence of bulimia nervosa from the 17th to late 19th century revealed that only a quarter of the overeating cases they examined actually vomited after the binges. There was no evidence of deliberate vomiting or an attempt to control weight.


20th century

Globally, bulimia was estimated to affect 3.6 million people in 2015. About 1% of young women have bulimia at a given point in time and about 2% to 3% of women have the condition at some point in their lives. The condition is less common in the developing world. Bulimia is about nine times more likely to occur in women than men. Among women, rates are highest in young adults. Bulimia was named and first described by the British psychiatrist
Gerald Russell Gerald Francis Morris Russell (12 January 1928 – 26 July 2018) was a British psychiatrist. In 1979 he published one of the first descriptions of bulimia nervosa, and Russell's sign has been named after him. Early life and education Gerald ...
in 1979. At the turn of the century, bulimia (overeating) was described as a clinical symptom, but rarely in the context of weight control. Purging, however, was seen in anorexic patients and attributed to gastric pain rather than another method of weight control. In 1930, admissions of anorexia nervosa patients to the
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from 1917 to 1929 were compiled. Fifty-five to sixty-five percent of these patients were reported to be voluntarily vomiting to relieve weight anxiety. Records show that purging for weight control continued throughout the mid-1900s. Several case studies from this era reveal patients with the modern description of bulimia nervosa. In 1939, Rahman and Richardson reported that out of their six anorexic patients, one had periods of overeating, and another practiced self-induced vomiting. Wulff, in 1932, treated "Patient D", who would have periods of intense cravings for food and overeat for weeks, which often resulted in frequent vomiting. Patient D, who grew up with a tyrannical father, was repulsed by her weight and would fast for a few days, rapidly losing weight.
Ellen West Ellen West (1888–1921) was a patient of Dr. Ludwig Binswanger who had anorexia nervosa. She became a famous example of Daseinsanalysis who died by suicide at age 33 by poisoning herself. Life Ellen West was born to a Jewish family in 1888. When ...
, a patient described by
Ludwig Binswanger Ludwig Binswanger (; ; 13 April 1881 – 5 February 1966) was a Swiss people, Swiss psychiatrist and pioneer in the field of existential psychology. His parents were Robert Johann Binswanger (1850–1910) and Bertha Hasenclever (1847–1896). ...
in 1958, was teased by friends for being fat and excessively took thyroid pills to lose weight, later using laxatives and vomiting. She reportedly consumed dozens of oranges and several pounds of tomatoes each day, yet would skip meals. After being admitted to a psychiatric facility for depression, Ellen ate ravenously yet lost weight, presumably due to self-induced vomiting. However, while these patients may have met modern criteria for bulimia nervosa, they cannot technically be diagnosed with the disorder, as it had not yet appeared in the
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...
at the time of their treatment. An explanation for the increased instances of bulimic symptoms may be due to the 20th century's new ideals of thinness. The shame of being fat emerged in the 1940s when teasing remarks about weight became more common. The 1950s, however, truly introduced the trend of aspiration for thinness. In 1979,
Gerald Russell Gerald Francis Morris Russell (12 January 1928 – 26 July 2018) was a British psychiatrist. In 1979 he published one of the first descriptions of bulimia nervosa, and Russell's sign has been named after him. Early life and education Gerald ...
first published a description of bulimia nervosa, in which he studied patients with a "morbid fear of becoming fat" who overate and purged afterward. He specified treatment options and indicated the seriousness of the disease, which can be accompanied by depression and suicide. In 1980, bulimia nervosa first appeared in the
DSM-III The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a c ...
. After its appearance in the DSM-III, there was a sudden rise in the documented incidents of bulimia nervosa. In the early 1980s, incidents of the disorder rose to about 40 in every 100,000 people. This decreased to about 27 in every 100,000 people at the end of the 1980s/early 1990s. However, bulimia nervosa's prevalence was still much higher than anorexia nervosa's, which at the time occurred in about 14 people per 100,000. In 1991, Kendler et al. documented the cumulative risk for bulimia nervosa for those born before 1950, from 1950 to 1959, and after 1959. The risk for those born after 1959 is much higher than those in either of the other cohorts.


21st century

In the 21st century, bulimia nervosa remains a significant public health concern. Data from 2001 to 2003 indicates that approximately 0.3% of U.S. adults experience bulimia nervosa in a given year, with a higher prevalence among females (0.5%) compared to males (0.1%). Globally, the age-standardized prevalence rates of bulimia nervosa have risen from 134.19 per 100,000 individuals in 1990 to 160.25 per 100,000 individuals in 2017, reflecting an annual increase of 0.71%.


See also

* Anorectic Behavior Observation Scale *
Eating recovery Eating recovery refers to the full spectrum of care that acknowledges and treats the multiple etiologies of anorexia nervosa and Bulimia nervosa, bulimia, including the biological, psychological, social and emotional causes of the disorder, through ...
*
Evolutionary psychiatry Evolutionary psychiatry, also known as Darwinian Psychiatry, is a theoretical approach to psychiatry that aims to explain psychiatric disorders in evolutionary terms. As a branch of the field of evolutionary medicine, it is distinct from the medic ...
*
Binge eating disorder Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
*
List of people with bulimia nervosa This is a list of notable people who have had bulimia nervosa. Often simply known as ''bulimia'', this is an eating disorder which is characterized by consuming a large amount of food in a short amount of time, followed by an attempt to rid onesel ...


References


External links

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