(Article revised January 2008)
Medical Director Cygnet Hospital Ealing, 22 Corfton Rd, Ealing
London W5 2HT
The Priory Hospital, Priory Lane, Roehampton, London SW15 5JJ
And: 51 Sloane St, London, SW1X 9SW
And: 19 Cliveden Place, Sloane Square, London, SW1W 8HD
Bulimia Nervosa is an illness that is most commonly found in girls of later adolescence and early adulthood. It is very rarely found in men. The main symptom is that of binge eating; eating large quantities of food in a short time. This behaviour may be extreme with enormous quantities of food, most typically carbohydrates being consumed. To prevent the otherwise inevitable consequence of weight gain these episodes are usually followed by attempts at food restriction and also often by vomiting, laxative abuse or excessive exercising. With time the binges may become multiple with repeating cycles over several hours in which the sufferer eats until full, then vomits and eats again. When the sufferer vomits after binging then the sufferer’s eating pattern becomes more chaotic with a total loss of any normal meal times and an increasing likelihood of more and more binging. Such is the drive to eat that they may scavenge leftovers from a dustbin or steal in order to feed the compulsion to eat. They generally find their own behaviour disgusting and are deeply ashamed of it so they almost always try to keep it secret.
Signs that may raise the suspicion that someone suffers with bulimia include a tendency to leave the table during and/or immediately after a meal to go to the toilet. Vomiting is most frequently induced by forcing two fingers of the right hand down the throat. This often causes a chronic blister just below the knuckle where it rubs on the upper teeth. Repeated vomiting quite often leads to swelling of the salivary glands that show as soft swellings at the base of the ears or just under the chin. If it goes on for many years the swellings can become hard and permanent.
Bulimia Nervosa may be considered as three separate illnesses that share the essential features described above. The subdivisions used here are Simple, Anorexic, and Multi-impulsive Bulimia Nervosa. There is quite a lot of overlap between them so that sufferers will sometimes show characteristics that belong midway between these subgroups.
Simple Bulimia Nervosa is an illness that begins most commonly when the girls are about 18 yrs of age. They tend to have been mildly under confident and unassertive but come from a broad range of unexceptional family backgrounds. They have probably made friends normally at school and are often fairly popular. The illness is frequently triggered by a period of unhappiness and this is often caused by a destructive relationship with a boyfriend. The feeling of self dislike focuses on appearance and dieting is begun in an attempt to improve self esteem. In contrast to an anorexic the diet is not very successful with the rigid control needed breaking down into bouts of overeating at an early stage. Vomiting is used as part of increased efforts to achieve the weight loss and so the cycle of binging and vomiting begins. There is more loss of control as the body's normal mechanisms of appetite control are over ridden and confused. The weight will remain close to normal, sometimes after a short period of slight weight loss, but the eating pattern becomes gradually worse partly because they discover that binging and vomiting reduces the negative feelings they had. This form of bulimia is the least severe but the severity varies considerably. It is likely that there are large numbers of girls with fairly mild symptoms that never come to medical help but there is a significant risk that it will slowly get worse with time. A common time for sufferers to seek help is when they are planning to start a family in their early twenties and are concerned about possible effects on having a successful pregnancy.
Anorexic Bulimia Nervosa is a variant of the illness that is preceded by a bout of Anorexia Nervosa. Quite often this anorexic episode is a brief one and the sufferer begins to recover without treatment. It is followed typically by a short period of stabilised weight just below that at which the menstruation may restart, around 46 kg. The control of the anorexic is not sustained and binging begins usually in a very small way but becomes more severe especially once vomiting begins. Often they begin by vomiting after what would for a normal person be an ordinary meal but this leads to a loss of control of the appetite drive and true binging, with a larger carbohydrate intake, gradually starts. Occasionally the vomiting and binging start first but then there is a period of significant weight loss in an anorexic phase that includes restrictive eating. The illness becomes dominated by the binging and vomiting behaviour but the weight remains low for a while before gradually rising to normal levels. In time their weight will usually become greater than average weight for height. The personality profile and backgrounds of these girls is very similar to a group with Anorexia Nervosa. A description may be found in the article "Introducing Anorexia Nervosa". When there are differences the Bulimic group seem to be slightly less obsessive and to be marginally more mature in emotional development. They are more likely to have boyfriends and to show their feelings.
Multi-impulsive Bulimia Nervosa is a severe variant of Bulimia Nervosa that begins in a similar way to Simple Bulimia and in a similar age group of girls. This group suffer with a range of abnormal behaviours all of which indicate problems of emotional and impulse control. Often some of these other behaviours are already causing difficulty before the Bulimia begins. In association with the eating disorder will be found a mix of other problems including drug abuse, alcohol abuse, deliberate self harm (usually cutting of forearms), stealing and promiscuity. They have a range of backgrounds but it is quite common to find that there is a high level of disturbance within the family. In personality they are likely to have shown evidence of poor impulse control from an early age and they often have rather poor records of schooling, academic achievement, or making friendships that last. They have a difficulty in modifying their behaviour because of predictable consequences of their actions and as result helping them to change the pattern of their lives often requires prolonged help. The severity of the illness as with all types of bulimia is quite variable and in this group of patients it seems to depend on nature and severity of the underlying personality difficulties.
Causes of Bulimia Nervosa
The causes of Bulimia Nervosa remain unknown although there is probably a small genetic contribution. In sub-clinical form bulimic behaviour is probably very common in our society. The incidence of Bulimia Nervosa is usually given as 3% of young women but the true incidence is likely to be much greater. The pressure to be thin and resulting abnormal eating patterns that are regarded as normal are probably partly to blame. Certainly the desire to be thin and attempts to restrict weight are the commonest triggers that provoke the illness. Once established bulimia influences the way that emotions are felt. It protects the sufferer from experiencing feelings that may be to them unbearable. It is paradoxical that bulimia causes them to become increasingly out of control in a wide variety of ways and yet it is the one thing that enables them to feel in control. Their fear of being without this protection maintains and increases the severity of the illness which comes to dominate other emotional experiences.
Once the illness has become established binges are triggered partly by the abnormal eating and distorted appetite drive and partly by underlying feelings. Periods of depression, boredom, and anger are likely to increase the risk especially when the sufferer is alone. It is a habit forming behaviour and some girls plan being alone and having food available in order to make it easier for them to binge and vomit. They may become dependant on this mechanism of controlling their feelings.
Risks of Bulimia Nervosa
Repeated vomiting causes a loss of stomach contents and because this includes the acid secretions that are needed for digestion it leads to changes of body chemistry. Laxative abuse causes similar distortion of chemistry and the two behaviours together are most likely to be dangerous. Major disturbance of the blood chemistry, particularly loss of potassium, and rupture of the stomach are occasional causes of sudden death but fortunately this is rare unless the behaviour is extreme. Acid from the stomach constantly washing over the teeth dissolves the enamel which will cause lasting damage particularly to the four central upper teeth. Irregularity of the menstrual cycle is common and sometimes it stops altogether. There is an association of ovarian cysts with the illness that is likely to reduce fertility but most are able to conceive normally once they have recovered. As with all eating disorders the greatest risks to health are from suicide or self harm as a result of feelings of depression and hopelessness.
Course and Outcome
Simple Bulimia Nervosa often runs a fairly benign course and there are probably many girls who have mild illnesses, never ask for help, and yet give it up successfully. When more severe it is often an illness that can be successfully treated on an outpatient basis. The sufferer needs to want to give up the illness more than she wants to manipulate her weight by vomiting. Treatment is often along behavioural lines at first and gradually focuses more on emotional problems. In experienced hands the outcome of such treatment is good.
Anorexic Bulimia Nervosa is more likely to need inpatient or day patient care especially if the weight remains low because restoration of normal weight is essential to restore more normal mechanisms of appetite control. The emotional disturbance is often greater and the degree of emotional maturity less so that greater support and psychological input may be needed. Correspondingly the outcome is a little more guarded but many will do well. Ultimately the outcome depends on the severity of the underlying problems and their successful resolution as it does with Anorexia Nervosa.
Someone with Multi-impulsive Bulimia Nervosa is only likely to seek treatment when severe as in other circumstances the sufferers are unlikely to want change. Often the reason that help is being sought is because of the effect of their behaviour on the family or the secondary effects such as being caught shoplifting. All the associated symptoms including bulimia itself enable the girls to switch off from and become unaware of emotional issues and in this state they refuse help. As a result they often need inpatient care in a highly structured environment where they are able to be prevented from acting out in self destructive ways. Treatment is likely to focus on a range of impulse control issues as well as underlying emotional problems. This is the most difficult of the types of bulimia to treat and the one with the least good outcome. Despite that many girls will eventually make good recoveries.
Treatment Options
Most sufferers should first go to their general practitioner. He/she may well have a good knowledge of the local availability of appropriate treatment. If specialist help is needed he should be consulted as to choice of person and place. Another source of unbiased advice is the Eating Disorders Association.
The N.H.S. has a number of eating disorder units often based within teaching hospitals. Many of these are excellent but the quality is very patchy. They often have long waiting lists and it may take several months to wait for an assessment and longer to start an agreed course of treatment. Your general practitioner should be able to find out what the situation is locally quite easily.
The private sector also runs eating disorder units and many of these are also
of good quality. However inpatient stays frequently run to several months so
cost may be high. For most people medical insurance is necessary and it is wise
to check the amount of cover available. The area where you live may not have
an eating disorder unit run by the N.H.S. If this is so the N.H.S. may buy treatment
from the private sector. Assistance will be needed from your general practitioner
and from the admitting hospital but in practice this means that the area health
authority may pay for private care on a private unit of your and the GP's choice.
Dr Rowan's Secretary is stationed in the Priory Hospital, Roehampton.
Direct line Telephone Number: (0044) or (0) 208 392 4211
Fax: (0044) or (0) 208 876 4015
Email peter.rowan@psychiatrist4u.co.uk