Type of paper: Research Paper

Topic: Bulimia, Eating, Psychology, Disorders, Nursing, Weight, Medicine, Behavior

Pages: 10

Words: 2750

Published: 2020/11/15

Bulimia is an eating disorder manifesting in episodes of eating large amounts of food in a very short time (bingeing) and then purges in an attempt not to gain weight. Purging activities include ingestion of laxatives and inducing vomiting. According to the Diagnostic and Statistical Manual for Mental Disorders, 4th Edition, the patient must indulge in the compulsory behaviors a minimum of twice weekly for 3 months for diagnosis (Rushing, Jones & Carney, 2003). Otherwise, another disorder may be indicated. People with bulimia use these activities in an attempt to take control of their lives and ease stress.

There are a number of possible causes of bulimia. These can include:

Biology. Genetics, hormones, or chemicals in the brain may influence the development of the disease and ability to recover.
Culture. The culture in the United States places strong emphasis on being extremely thin. Being slender is a standard of beauty for many women based on advertisements and the entertainment industry.
Personal feelings. Bulimics frequently have a poor self-image and express feelings of helplessness.
Life changes or stressful events. Events such as bullying, rape, changing locations of work or home can lead to seeking relief through bulimic activities.
Family attitude. A person is more likely to develop bulimia if a family member has it. Parental standards on being thin or striving to please a parent frequently manifests in bulimia.
Substance abuse. The inappropriate use of drugs can lead to a distorted sense of self or paranoia concerning the perceptions of others. The National Center on Addiction and Substance Abuse at Columbia University reports a substance abuse problem in 30 percent to 70 percent of patients diagnosed as bulimic (Vastag, 2001)
Patients with bulimia frequently do not realize they are ill and are not receptive to the prospect when confronted. As a result, they may resist treatment and be uncooperative with efforts to address their behavior. In fact, some patients can hide their behavior for years until it creates a life-threatening condition. In some instances, treatment can be a long-term process and relapse is common.


Bulimia nervosa was originally described by Gerald Russell in 1979 (Russell, 1979). It was originally thought to be a variant of anorexia nervosa. However, subsequent research has resulted in enough differences that they are now considered to be two separate syndromes. Russell drew his results from a study of 30 patients he treated between 1972 and 1978 (Medindia, 2015). His original description follows:
"In 30 patients whose illness bears a close resemblance to Anorexia Nervosa,episodes of overeating constituted the most constant feature of the disorder Overeating was often overshadowed by more dramatic clinical phenomena--intractable self-induced vomiting or purgation The constancy and significance of overeating invite a new terminology for description of this symptom - Bulimia Nervosa." (Gerald F.M. Russell, 1979)
Fairburn first described cognitive-behavior therapy as a treatment for bulimia nervosa in 1981. The two goals are to modify abnormal perceptions toward food and to stop the cycle of bingeing and purging.

Signs and Symptoms

The populations most at risk are white, middle-class females (mostly teenagers and college students), individuals with a family history of substance abuse and mood disorders, and people with low self image (University of Maryland Medical Center, 2013). Bulimics are characterized as impulsive, extroverted, self-critical perfectionists who are uncontrolled emotionally (Rushing, Jones & Carney, 2003).
Initial signs of bulimia to cause suspicion in friends and family members are ingestion of large amounts of food without any evident weight gain, excessive exercising, and eating very small amounts of food (Sedghizadeh, 2013). The suspected bulimic may be overly concerned with body weight or appearance of being overweight.

The signs and symptoms of bulimia are secondary to malnutrition, mental distress, and dehydration.

Mouth problems will include cavities, gum disease, ulcers in the mouth, erosion of tooth enamel with lingual decay, swollen parotid glands, and sensitivity to cold and hot foods.
Mental health problems may be noticed with anxiety, low self-esteem, shame, depression, and fear of weight gain. Patients may also suffer from obsessive-compulsive disorder or other psychiatric illnesses.
Stomach problems from frequent vomiting, use of laxatives, and stress can result in pain, delay with emptying, and ulcers in the stomach. Bowel movements may be irregular and bloating may be present. Diarrhea, constipation, and abdominal cramping are frequently seen. The throat and esophagus will also display signs of trauma with soreness, tears, and irritation.
As muscles begin to deteriorate from malnutrition, muscle fatigue will become apparent. The skin will also become very dry and the knuckles on the first two fingers become abraded from pushing against the teeth while inducing vomiting.
Females will have irregular or absent menses, generally due to decreased body fat. A soft layer of hair may grow over the entire body as it tries to retain heat in the absence of body fat.
Hypokalemic metabolic alkalosis is also an indicator of bulimia nervosa indicated by heart problems such as irregular heartbeat, a low blood pressure, a slow pulse, and weakened heart muscle. It is possible the patient will go into cardiac arrest, the most common cause of death in bulimic patients. Therefore, an electrocardiogram should be ordered if the patient is underweight, exhibits electrolyte abnormalities, chest pain, or heart palpations (Rushing, Jones & Carney, 2003).
The patient, friends, or family will report behaviors associated with binge-eating and purging. These patients will frequently present to their primary care physician; these health care providers are in an excellent position to recognize indications and provide early treatment and referrals (Diana & Polimeni-Walker, 2004).

DSM-V: Diagnostic Criteria

“Eating Disorder Diagnostic Criteria from DSM IV-TR
307.1 Anorexia Nervosa

Refusal to maintain body weight at or above a minimally normal weight for age and

height, for example, weight loss leading to maintenance of body weight less than 85%
of that expected or failure to make expected weight gain during period of growth,
leading to body weight less than 85% of that expected.

Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way one's body weight or shape is experienced, undue influence
of body weight or shape on self evaluation, or denial of the seriousness of the current
low body weight.
In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive
menstrual cycles. A woman having periods only while on hormone medication (e.g.
estrogen) still qualifies as having amenorrhea.


Restricting Type: During the current episode of Anorexia Nervosa, the person has not
regularly engaged in binge-eating or purging behavior (self-induced vomiting or misuse
of laxatives, diuretics, or enemas).

Binge Eating/Purging Type: During the current episode of Anorexia Nervosa, the

person has regularly engaged in binge-eating or purging behavior.
307.51 Bulimia Nervosa

Recurrent episodes of binge eating characterized by both

Eating, in a discrete period of time (e.g., within any 2-hour period), an amount
of food that is definitely larger than most people would eat during a similar period of
time and under similar circumstances.
2. A sense of lack of control over eating during the episode, (such as a feeling that
one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting,
or excessive exercise.

The binge eating and inappropriate compensatory behavior both occur, on average, at

least twice a week for 3 months.

Self evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Purging Type: During the current episode of Bulimia Nervosa, the person has regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Nonpurging Type: During the current episode of Bulimia Nervosa, the person has used

other inappropriate compensatory behavior but has not regularly engaged in self-induced
vomiting or misused laxatives, diuretics, or enemas.” - American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2000
Changes in DSM-5 DSM-5 (2013) contains revisions to diagnostic criteria for bulimia nervosa and binge-eating disorders. The criteria for bulimia nervosa was reduction of the frequency of compulsory behavior to once a week from the twice a week criteria in DMS-IV.
Researchers have noticed that a large number of patients with eating disorders did not meet the classifications for the DSM-IV criteria for bulimia nervosa and anorexia nervosa. Therefore, they were given the diagnosis of “eating disorder not otherwise specified.” Therefore, “binge eating disorder” was approved for its own category in DSM-5. Its definition includes episodes of overeating accompanied by feelings of being out of control. These episodes may occur when the patient does not experience feelings of hunger. Due to feelings of disgust, guilt, or embarrassment, the binge eating behavior may be performed in private. Frequency must be at least once a week over a period of three months to meet the criteria for diagnosis. The inclusion of the diagnosis is made to understand the difference between binge eating and overeating; the difference is increased severity, less common occurrence in the general populations, and is associated with significant psychological and physical issues.

Treatment for Bulimia

The patient initially is hydrated intravenous saline and referrals are made for psychiatric and dental evaluations. Comprehensive treatment plans also include nutrition counseling and monitoring of the patient’s physical state.

Nutritional Rehabilitation

There are several strategies for nutritional rehabilitation. These include establishing a pattern of regular meals with a normal intake, creating a more positive attitude toward the eating disorder, encouraging a normal amount of exercise, and resolving condition that lead to inappropriate eating behaviors such as anxiety.


Therapy for the individual, family, or in groups can be effective (Krysanski & Ferraro, 2008). The predominant approach is cognitive-behavioral (CBT). If there is a spouse involved, marital therapy is indicated. In the CBT method, therapy runs for 20 weeks in three overlapping phases (Agras, Walsh, Fairburn, Wilson & Kraemer, 2000). In the first phase, the patient is taught about her disease and the actions that contribute to it. The patient is responsible for keeping a detailed food diary, including any incidences of bingeing and/or purging. These records are used in the therapy sessions. The second phase teaches the patient how to pick healthy foods and more time is allotted to addressing inappropriate thoughts about food. The third phase incorporates the last three therapy sessions, focusing on maintaining acquired habits and preventing relapse. A combination therapeutic approach combining CBT and fluvoxamine has found to be more beneficial than use of one or the other (Walsh, Wilson & Loeb, 1997). It has been found that after completion of CBT, 45 percent of the patients no longer binge and purge, and 35 percent can no longer be diagnosed as bulimic.
Some stress-reduction techniques improve relaxation and body image. These include yoga, tai chi, and meditation. The University of Maryland (2013) reports a study that found guided imagery assisted bulimic patients in feeling better about their bodies, promoted healthy eating habits, reduced binge eating and purging, and made patients feel more capable of comforting themselves.


Antidepressant medications have been successful when used with therapy. Psychotropic drugs with selective serotonin reuptake inhibitors (SSRIs) have been found to be helpful. These can include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and (Zoloft) (University of Maryland Medical Center, 2013). Prozac has been known to cause suicidal thoughts in young people and patients taking this medication should be watched closely. However, it has been shows to be effective in controlling urges to binge and purge, particularly in conjunction with cognitive-behavioral therapy (Rushing, Jones & Carney, 2003). Patients on the medication show a significantly decreased incidence of relapse (Romano, Halmi, Sarkar, Koke & Lee, 2002). Case studies of 5 patients prescribed with Zoloft demonstrated a reduction in their eating disorder behavior and an adequate weight gain (Frank, Kaye & Marcus, 2001). Prozac remains the only drug approved by the United States Food and Drug Administration for the treatment of bulimia nervosa.

Potassium and iron supplements, along with others, may be prescribed by the physician to address deficiencies.

Bulimia nervosa is an eating disorder that usually presents in the primary care setting. The patient has abnormal perceptions concerning food and eating although they often maintain normal body weight. This is a disease that responds well to therapy when caught early, so primary physicians should be alert in the high-risk populations for signs of the disorder.
A number of famous people have suffered from bulimia: singer Paula Abdul, Princess Diana of Wales, actress Lindsey Lohan, and singer Victoria Beckham (Edreferral.com, 2015). A famous person who died from bulimia was singer Karen Carpenter. Luisel Ramos was a prominent model from Uruguay who, in 2006, died at the age of 22 from heart failure secondary eating disorders. She was participating Fashion Week and in the public outrage that followed Luisel’s death, a minimum BMI of 18 was made mandatory for all models. That same year, fashion designers in Italy prohibited models wearing size zero models from their shows. The following year, Luisel’s 18-year-old sister, also a model, died of an apparent heart attack thought to be due to malnutrition.
Society’s standard of beauty for women being excessively thin is a large part of the problem for patients with bulimia. Females in America are bombarded daily with images stressing the desirability of being slender and the condemnation of being overweight. Their feelings of poor self-image are reflected as obesity although their weight may be normal. Obsessive-compulsive tendencies combine with a need for acceptance to focus on body weight as an unrealistic goal. However, more and more women are stepping forward condemning ridiculously low weight, false embellishment, plastic surgery, and other unhealthy methods of attempting to achieve the ideal set forth in the media. It is the responsibility of men and women alike to take a vocal stand against this type of advertising and work on an individual basis to promote a healthy lifestyle rather than one focused on obsessive striving for the impossible.


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Comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy for
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(2000). Eating Disorder Diagnostic Criteria from DSM IV-TR. Retrieved 16 February
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eating, anorexia, eating disorders. Retrieved 16 February 2015, from
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eating disorders: Five case reports. International Journal Of Eating Disorders, 29(4),
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