General Description

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. It is characterized by episodes of binge eating; eating large quantities of food in a short time. This behavior may be very severe with enormous quantities of food, most typically carbohydrates being consumed. To prevent the otherwise inevitable consequence of weight gain there are periods of food restriction and often vomiting, laxative abuse or excessive exercising. When vomiting is used then the binges may become multiple with repeating cycles over several hours in which the sufferer eats until full, then vomits and eats again. With increasing severity the girls' lives become more chaotic with the focus increasingly on the bulimic behavior. Such is the drive to eat that they may scavenge leftovers from a dustbin or steal in order to feed the compulsion. They generally find their own behavior disgusting and are deeply ashamed of it so that it almost always occurs in secret.
Signs that may indicate that there is a problem include a tendency to leave the table immediately after a meal. 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 become hard and permanent.

Three Types of Bulimia nervosa

Bulimia Nervosa is best considered as three separate illnesses that share the essential features described above. They will be discussed below under three different headings; Simple, Anorexic, and Multi-impulsive Bulimia Nervosa. There is quite a lot of overlap between them so that there are a number of sufferers who 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 are a fairly normal group before the illness. 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 in a normal way 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 cheating. Vomiting is used as part of increased efforts to achieve the weight loss and so the cycle of bingeing 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 but the eating pattern becomes gradually worse. 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 babies.

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 stabilized weight just below that at which the menstruation may restart, around 46 kg. The control of the anorexic is not sustained and bingeing 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 bingeing gradually starts. Occasionally the vomiting and bingeing 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 bingeing and vomiting behavior but the weight remains low for a while before gradually rising to near and in time above normal. The personality profile and backgrounds of these girls is similar as for a group with Anorexia Nervosa. A description may be found in the leaflet "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. The 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 suffers with a range of abnormal behaviors all of which indicate problems of emotional and impulse control. Often some of these other behaviors 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 friends that last. They have a difficulty in modifying their behavior 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 varied and in this group it seems to depend on severity of the underlying abnormality personality.

Causes of bulimia nervosa

The causes of Bulimia Nervosa remain unknown although there is probably a small genetic contribution. In sub-clinical form bulimic behavior 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 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 all emotional experience.
Once the illness has become established the trigger to binge is often partly or wholly related to feelings. Periods of depression, boredom, and anger are likely to increase the risk especially when the sufferer is alone. It is a habit forming behavior and some girls plan being alone and having food available in order to make bulimia easier. They can become addicted to the emotional feelings that are generated in this way.

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 behaviors 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 behavior 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 are recovered. As with all eating disorders the greatest risks 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 out-patient 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 behavioral 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 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 behavior 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.

The clinical picture:

Bulimics patients are typically dissatisfied with their own body shape. They are often preoccupied with the idea that they are overweight and that particular parts of their body are grotesque and unattractive.
The patient who suffers from this illness feels depressed and also a lack of self-esteem.
Many of those who suffer from bulimia show a number of other psychological disturbances, some of which may have played a causal role in the development of the bulimia, and others of which may have developed as a consequence of the disorder.
Bulimic women frequently describe themselves as worthless and often regard their situation as helpless and hopeless.
Other psychological symptoms associated with bulimia include anxiety, obsessional problems, and various kinds of dysfunctional impulsive behavior. The social anxiety experienced by many bulimic patients may become especially acute when, for example, they are expected to eat in the company of other people.

Treatment Options

Most sufferers will first go to their general practitioner. He may well have a good knowledge of the local possibilities for 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 on 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. 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 under the Extra Contractual Referral scheme. 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.

Anorexia Nervosa

The term “anorexia nervosa” was first used by the English physician William Withey Gull in 1868 to label a particular form of disease occurring mostly in young women and characterized by extreme emaciation. The condition was apparently rather rare until relatively, however, and the present high level of concern about anorexia, both by clinicians and by lay people, reflects the fact that in recent decades the prevalence of the disorder appears to have risen at an alarming rate.

Anorexia nervosa is an illness that usually occurs in teenage girls, but it can also occur in teenage boys, and adult women and men. People with anorexia are obsessed with being thin. They lose a lot of weight and are terrified of gaining weight. They believe they are fat even though they are very thin. Anorexia isn't just a problem with food or weight. It's an attempt to use food and weight to deal with emotional problems.

• Behavioral abnormalities

Most of the unusual and disturbed behaviors associated with anorexia are related to the pursuit of thinness.

Patients are not truly anorectic, but struggle against hunger to achieve an unrealistic degree of weight loss. For most anorectics, weight loss is accomplished through dietary restriction and exercise (restrictive group), although up to 50% will also self-induce vomiting or take purgatives (bulimic group).
Perceptual disturbances, insisting they are fat despite profound weight loss. They distort hunger awareness, deny fatigue, and fail to recognize emotional states such as anger and depression.
Despite their frequent insistence that they are not hungry, it appears that most anorexic patients do feel hunger pangs and retain an appetite for food. Their avoidance of eating is, therefore, a form of social-denial.

• Emotional state

Personality Characteristics of Individuals With Eating Disorders
People with Anorexia Nervosa:

• Perfectionists
• Conflict avoidant
• Emotionally and sexually inhibited
• Compliant
• Approval seeking
• Excessively dependent
• Socially anxious
• Fear of spontaneity
• Reluctant to take risks
• Practice food rituals

The majority of anorexic patients are emotionally disturbed in some way. Anxiety and depression are very common, and many patients experience rapid mood-swings.

Cognitive aspects

According to the body-image hypothesis, many anorexic patients suffer from the disillusion that they are fat. Many clinicians are familiar with patients who continue to insist that hey are too fat even when they are in fact, emaciated, and when relatives try to convince such people of the reality of their physical state, perhaps by pointing to the degree of weight loss or showing photographs, they often meet with a response of firm denial or of extreme hostility.

Low self-esteem

Their tendency towards obsessionality may show itself in perfectionism and by setting themselves the highest standards they may set themselves up for failure.

"... lost in the darkness of my own circumstance, criticizing echoes leaving me awake in the night... the barrier and blockades that keep me safe and in control while I pretend that I am okay... "

It is important to point out that there can be a number of ways a person suffering from Anorexia can portray their disorder. The inherent trait of a person suffering Anorexia is to attempt to maintain strict control over food intake. In a number of cases a man or woman suffering will seem to eat normal meals with only periods of restriction. Anorexics are sometimes known to eat junk food, particularly candy, to drink a lot of coffee or tea, and/or to smoke. They may deny hunger, make excuses to avoid eating, will often hide food they claim to have eaten, use diet pills to control appetite, or attempt to purge the food away with self-induced vomiting, or by taking laxatives.

"...Emotions control me... make me hide in a safe place of silence.... my mind stays distant from what my heart feels. If I say it... it's real... so I say nothing. I can't touch it... if I did I would curl up or crumble. I may seem to be made by heart of stone.... but really just chalk... and I'm afraid to face the possibility that I could easily turn to dust..."


In the US: Anorexia nervosa, meeting full Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria, has been found to occur in 1 out of 100-200 females in late adolescence and early adulthood. Individuals who are sub threshold for the disorder are encountered more commonly. Incidence rates have increased in recent years. A familial pattern has been noted.

Internationally: Rates of anorexia nervosa are similar in all developed countries with high economic status. The disorder is far more prevalent in industrialized societies where food is abundant and thinness is a measure of feminine attractiveness.

Mortality/Morbidity: Mortality associated with anorexia nervosa is high; 6-20% of patients eventually succumb to the disorder. Death usually is secondary to starvation or suicide.

Race: While frequency of anorexia nervosa is significantly higher in white populations than in nonwhite populations, the coexistent effect of socioeconomic class is difficult to isolate.

Sex: More than 90% of cases occur in females. However, it should be emphasized that males represent approximately 10% of anorexia nervosa cases, a fact that often is overlooked.

Age: Although more commonly the illness begins between early adolescence (13-18 y) and early adulthood, earlier-onset and later-onset are encountered. In some patients with early-onset (age 7-12 y), obsessional behavior and depression are common. In a few cases, exacerbations of anorexia nervosa and symptoms similar to obsessive-compulsive disorder have been associated with pediatric infection-triggered autoimmune neuropsychiatric disorders.

Biological models

Genetic factors: Twin studies suggest that around 60 per cent of MZ twins are concordant for the condition. Research has also indicated that other relatives may be slightly increased risk, although this does not necessarily implicate genetic factors. Such a family link might well be explicable in terms of environmental or social interactional factors rather than the genetic similarity between blood relatives.

Stress and anxiety are emotions experienced intensely by sufferers with anorexia nervosa. Stress and anxiety involve the norepinephrine neurochemical system. The NET is a protein that plays a role in this system by shipping the chemical called norepinephrine back into neurons. The NET gene provides the instructions to make the NET. An on-off switch (promoter) in the NET gene determines how many NETs are made. Variation in the DNA sequence of the promoter may increase or decrease the number of NETs being produced. Since this may begin disease processes, the researchers studied the DNA sequence of the promoter. They found a big piece of DNA in normal people, which had never been observed before. This DNA was found in two different sizes: one long and one short. When sufferers with the restricting type of anorexia nervosa, and their parents were tested, the parents were shown to pass on the long form significantly more often than the short form to their children. This shows that a person who inherits the long form has an increased chance of developing the restricting type of anorexia nervosa.
The study findings, published in the August issue of Molecular Psychiatry, are clear-cut and are set to turn future genetic studies of anorexia nervosa towards the norepinephrine neurochemical system. This should allow greater understanding of the biological mechanisms behind the development of this devastating illness, which has the highest death rate of all psychiatric disorders. Scientists are optimistic that the research will allow earlier identification and treatment of those who are vulnerable to developing anorexia nervosa, and will also encourage the design and use of new treatments to modify the way sufferers feel stress. This research also shows that the blame often placed on the family environment for causing this disorder is unjustified.

Serotonin :

At least some of the symptom of anorexia nervosa are also present in obsessive- compulsive disorder (OCD). One explanation for this overlap involves another neurotransmitter, serotonin. It is suggested that disturbances of serotonin activity may lead to a cluster of symptoms, which include rigidity, anxiety, obsessions and compulsive behaviors.

The relationship between anorexia nervosa and zinc deficiency is controversial and the subject of many studies.
Symptoms of zinc deficiency (weight loss, appetite loss, and behavior changes) resemble those of anorexia nervosa to some extent. This has led some researchers to theorize that low zinc levels may be related to the onset of the eating disorder.

Psychoanalytic models:

Psychoanalytic theory adheres to the notion that symptoms serve as a defense, which masks an underlying core set of more primitive issues and dynamics. One such central issue is a fear of and resistance to growing up. Beneath this issue, psychoanalytic folklore describes an even more primitive core dynamic known as oral impregnation. In oral impregnation, the female believes if semen is swallowed she will become pregnant. In fact, fear of fatness has been viewed as a rejection of any possible pregnancy. Once the underlying core dynamics are recovered and made conscious (the return of the repressed), the anorexic symptoms reportedly dissipate.

Psychological models:

One central focus for the analysis of the causes of anorexia is the patients initial decision to lose weight. We need to understand what might lead toi such a decision, and how the iitial dieting can then develop into a life-threatening disorder.
Most people with anorexia nervosa should be managed on an outpatient basis with psychological treatment provided by a service that is competent in giving that treatment and assessing the physical risk of people with eating disorders.
* People requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding) in combination with psychosocial interventions.
* Family interventions that directly address the eating disorder
should be offered to children and adolescents with anorexia

Methods of Clinical Assessment

In order for a person to be diagnosed with anorexia nervosa, they must possess the two essential psychological symptoms of the drive for thinness and the body image distortion problem. According to the DSM-IV, anorexics are categorized into two categories, restricting and binge-eating/purging types. Another assessment device is the Eating Attitudes Test and the Eating Disorders Inventory. The evaluation of an affected person should be multidimensional and comprehensive because of the severity of this problem.

After this has taken place, a formal interview with the client is conducted. This interview consists of many components. The history of the client's weight is assessed as well as the extent to which he or she is immersed with the ideas of body weight and shape. If the counselor possesses a firm, understanding perspective, the client will more likely open up and share issues with the advisor. As long as the interviewer knows that the symptoms expressed by the client are due to the eating disorder itself (in this case starvation), the counselor can grasp the problem in a tight manner. Other issues discussed between the interviewer and the client include past history of emotional disturbance, past medical history, family history, current family situation, family eating patterns, family attitudes about weight, and other personal history. Another important criterion that must be addressed is the presence or absence of past or present physical or sexual abuse because this is a significant determinant of a person possessing an eating disorder.


The first step in the treatment of anorexia is to aid the client in adapting a more standardized eating pattern. A dietitian may intervene at this point to assist the affected person to adopt more healthy eating behaviors. The counselor's role is to gradually help the client begin to adopt a more normal eating style (Shekter-Wolfson et al 13). In all cases, however, there are six goals of any treatment process:

1) To treat the medical complications
2) To revive a normal state of eating
3) To provide guidance on nutrition and exercise
4) To alter distorted views through CBT
5) To optimize support by educating the family
6) To enhance self-esteem with or without medication (Anonymous 101)

Cognitive Behavior Therapy

The most common form of outpatient individual therapy is cognitive behavioral therapy (CBT). This type of therapy focuses on the thoughts that envelop food and eating and presents a challenge to the dysfunctional beliefs on the part of the anorexic. One of the main goals of CBT is for the affected person to acquire a more self-focused and self-observant approach, so the person is asked to keep a diary of food intake and a journal of thought processes during the treatment period. There is still much more work to be done to assess whether CBT is as or more effective than other treatments of anorexia nervosa.

Interpersonal therapy is a broadened form of psychotherapy in which the focus is upon the patient's relationships with others and with the therapist. Many psychologists believe that many anorexic people also face shortages in psychosocial functioning may also be a factor in the lengthiness of an anorexic's condition. More research is needed to assess whether new and improved elements should be added to the treatment agenda, but the sense is that programs on sexuality or an interpersonal approach should be added to the CBT method

Almost every type of psychotherapy has been used on anorexic patients and all have been proven to be effective However, more structured and organized forms of psychotherapies, including behavioral therapy, tend to work more effectively early on in the treatment process while more psychodynamic treatments like behavioral or family therapy are used more gradually for a period of one to two years. A longitudinal study was conducted with 24 anorexic patients who were continuously receiving inpatient treatment. A comprehensive behavior therapy process lead to a significant improvement in body weight, eating habits, and body image and these results remained for 7 years when the follow-up was conducted. At the 7 year point, most of the patients had improved more so than at the one year point.

In cognitive behavior therapy for anorexia, the disorder is treated as if anorexia is nothing more than a fight for freedom, intelligence, self-respect, and self-discipline. Another goal of CBT is to correct the unhealthy cognitive processes that are causing the distorted beliefs. Even though most of these techniques are not used during periods of emaciation where the main goal is for the patient to regain weight, many people consider psychodynamic psychotherapies and cognitive treatment to be the most advantageous interventions for aiding the patients in keeping the weight on their bodies as well as to ease psychological maturation and improvement. There are six cognitive approaches that are widely used in CBT:

1) Education about the disorder
2) Providing informational answers to questions in regard to weight, calorie intake, and changing health status
3) Showing the patient to recognize and focus upon negative thoughts and other emotions linked to the distorted beliefs and fixations associated with weight, body shape, nutrition, exercise, and other aspects of the disorder.
4) Teaching the patient to come up with and replace alternative, more productive and positive thoughts for the negative ones
5) Problem-solving discussions
6) Teaching alternative coping strategies