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Bulimia Nervosa

Bulimia Nervosa

Description

Bulimia nervosa is an eating disorder in which subjects rapidly consume an excessive number of calories in uncontrollable eating binges. The usual cycle is a binge period that lasts for no longer than two hours, followed by either fasting, taking diuretics or laxatives, or purging the food by vomiting. Commonly referred to as "the secret addiction", binging is usually done in secrecy and isolation.

As with anorexia, the disorder is much more common among females than males, although the actual incidence of bulimia for each gender is not known.

Although bulemics may be overweight or underweight, they generally maintain their weight within normal range, making detection and diagnosis difficult.

They are less physically obvious than anorexics (see Anorexia Nervosa).

While some bulimic patients may have previously had anorexia nervosa, it is possible to have bulimia nervosa and anorexia nervosa at the same time, in which case it is commonly referred to as bulimic anorexia or bulimarexia.

Causes

A thorough review of the literature on bulimia nervosa indicates there is little consensus on its cause. Theories abound about whether the disorder caused by psychological, behavioral, biochemical or nutritional factors, or any combination of these.

Psychological View
Until recently, the predominant theory was bulimia is a psychological disorder: The bulimic is a perfectionist who is self-critical and sees life in extremes. The bulimic feels pressured to be thin, is unable to remain on a diet, feels like a failure and consequently eats much more, thus confirming his or her lack of control over situations.

If the psychological perspective is correct, then psychotherapy should be an effective treatment. However, research does not support psychotherapy as a successful treatment strategy. While literature on psychotherapeutic intervention abound, a major review of studies of both bulimia and anorexia nervosa found them "hopelessly inconclusive."

Family as Cause
No evidence exists to support the view families are the causative factor. The only studies supporting this view were of extremely flawed design and control--no control groups, no control for genetic or other variables, and no blinding.

Behavioral Disorder (S-R)
Behavioral psychologists focus on defining the stimulus-response patterns associated with the problem. They then can determine ways to break the destructive pattern by teaching the patient alternative behaviors or responses. For instance, if loneliness or emptiness is viewed as being the situation (stimulus) triggering the binging (response), the focus is on teaching and reinforcing healthier reactions to the loneliness (stimulus). This perspective is often viewed as shallow, and as a superficial and temporary solution to a deeper and more generalized problem.

Affective Disorder
The newest theory about bulimia nervosa is that it is caused by a major affective (mood) disorder, depression. Therefore, the predominate opinion holds that the depression must be treated with an antidepressant drug.

This theory has led to widespread use of three classes of antidepressant drugs in the treatment of bulimia nervosa: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (and their relatives) and triazolopyridines. However these drugs tend to cause various side effects, including a dry mouth, heart arrhythmias, constipation, fatigue, light-headedness and an increased appetite.

All three classes of antidepressants have been reported to work in a percentage of bulimics, lending support to the theory of depression as the underlying cause of bulimia nervosa. Among studies comparing the effectiveness of various antidepressants, imipramine has proven to be the most effective.

The depression theory believes biochemical imbalances may be causing the bulimia. Bulimics have been found to have deficient levels of a brain neurotransmitter called serotonin. Neurotransmitters carry signals from one nerve to another in the nervous system. Fluoxetine, an antidepressant, acts to inhibit the uptake of serotonin between the nerves. This leaves more serotonin for neurotransmission between the nerves, thereby lessening the purported deficiency. Researchers are still unsure of the success of this drug in curing bulimics, and it has not yet been approved for general use by the U.S. Food and Drug Admininstration (FDA).

Unfortunately, no theory has yet explained why bulimics have a serotonin deficiency, or if in fact this is the real reason for the bulimia.

In spite of the success reported with antidepressants, certain bulimics may not respond favorably to them. Specialists in eating disorders have reported when antidepressant medications fail to be effective, different combinations are tried. These include: MAOIs with L-tryptophan, and lithium carbonate plus carbamazepine, the former a prescription mineral salt having known treatment applications in manic-depressive illness. Any of the drug treatments discussed will require supervision by a licensed physician.

Caution must be exercised when taking MAOIs as antidepressants. Individuals taking MAOIs must avoid consuming aged cheeses, pickled herring, sour cream, chicken livers, or broad-bean pods, since serious side effects can occur. In bulimia, side effects occur easily unless there is adequate vigilance of the foods consumed. For example, most bulimics tend to crave a variety of carbohydrates (sugars and starches).

If the bulimic binges on pizzas, which may be made with an aged cheese, a reaction can occur. Therefore, unless the bulimic believes their binges are under control and/or restricted to safe foods only, MAOI may not be the safest antidepressant to take. As in all cases where drugs are involved, a physician should be consulted. Another area of research has been into the possible relationship between bulimia and nutritional imbalances. A 12 year study of bulimics found bulimia is a physical disorder camouflaged or concealed by the psychological problems it creates. By studying the bulimic's history before the onset of the bulimic behavior, it was discovered that the nature of prior eating choices before the binge-purge cycle began was very important and helped in explaining how the disorder ever began. From this finding came the discovery that bulimic's binges are physically induced by:

1. malnutrition resulting from severe caloric restriction, and/or
2. fluctuating levels of blood sugar or insulin.

A placebo-controlled blinded study on bulimics supported these findings. The author of the study felt that any diet with fewer than 1400 calories a day, no matter how well balanced, could cause binge eating behavior. It is argued that the malnutrition from restricted diets in and of itself is sufficient to cause the psychological problems often blamed for the bulimia.

There is considerable support for malnutrition being the cause of psychological disorders. Bulimics, who become bewildered at losing control of their diet habits, despondent over their unsuccessful attempts at weight loss and fear additional weight gains, may further restrict their caloric intake, while exercising furiously and/or having panic purges.

Panic purges can contribute to electrolyte imbalances, glycogen depletion, blood sugar alterations, dehydration, and further loss of nutrients and calories. These effects may all act with the dietary restrictions to trigger another binge, thus exacerbating the vicious binge-purge cycle.

Further support for this theory comes from the fact that rapid accelerated conversion of food into the body tissue following a period of severe caloric restriction (hyperlipogenesis), can cause deregulation of eating in a manner resembling the development of tolerance to abusive substances, like alcohol or illicit drugs. This is known as adaptive hyperlipogensis.

These findings suggest the treatment of bulimia requires acombination of some type of cognitive-behavioral self-control strategies, combined with diet therapy.

Signs & Symptoms

Bulimia nervosa is an eating disorder that can cause serious, even fatal medical consequences. Side effects are:

Tooth decay (from bringing up a very acidic stomach juice [hydrochloric acid] which can etch the tooth enamel, weakening the tooth`s outer defenses.)
Sore throat
Esophageal inflammation
Swollen glands
Rupture of the stomach
Disruption of electrolyte and fluid balance
Cardiac arrhythmias
Liver damage
Mental depression

The current diagnostic criteria for bulimia nervosa, as primarily used in North America are:

1. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time usually less than 2 hours.

2. At least three of the following:

a. consumption of high-caloric, easily ingested food during a binge
b. inconspicuous eating during a binge
c. termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting
d. repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diurectics
e. frequent weight fluctuations greater than 10 pounds due to alternating binges and fasts

3. Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.

4. Depressed mood and self-deprecating thoughts following eating binges.

5. The bulimic episodes are not due to anorexia nervosa or any known physical disorder.

Additional characteristics of bulimia are: an intense fear of being unable to stop binge eating; a depressed mood; and, the awareness that the eating behavior is abnormal.

Nutritional Supplements

Structure & Function:
        Nutrients for Brain Support &
        Multi Vitamin/Multi Mineral Formulas


---------------------------------
General Supplements
---------------------------------


Zinc*        

Rebuilding a sound nutrient base is, of course, imperative.


* Please refer to the respective topic for specific nutrient amounts.

Note: All amounts are in addition to those supplements having a Recommended Dietary Allowance (RDA). Due to individual needs, one must always be aware of a possible undetermined effect when taking nutritional supplements. If any disturbances from the use of a particular supplement should occur, stop its use immediately and seek the care of a qualified health care professional.

Dietary Considerations

The major hypothesis on diet and bulimia speculates that purges are physically induced by:

1. malnutrition states resulting from caloric and nutrient restriction

2. fluctuating levels of blood sugar (glucose) and/or insulin

In a placebo-controlled blind study of 20 women diagnosed as having bulimia nervosa, all stopped their binge-purge behavior after receiving a nutrient-dense flexible food plan of not fewer than 1400 calories. This plan was devoid of caffeine, alcohol, refined sugar and flour products, cigarettes, medication and flavor enhancers, while containing little salt. Diet sodas (caffeine and sugar free) were restricted to one a day. Produce (vegetables and fruits) was either fresh or frozen. Daily supplements consist of 1 gram of vitamin C, one 50 mg/microgram vitamin B complex a day, and one multiple vitamin/mineral formulation a day. Aerobic exercise is restricted to no more than 60 minutes per day. Anaerobic exercises, such as weight lifting, are not permitted.

This program, under professional supervision should be continued for at least six weeks, and evaluated for results. Antidepressants can be used while this diet therapy is occurring, however, caution must be shown in taking any MAOIs as to food selections.

Homeopathic Remedy

1.*Glonoinum tinct.                15C
2.*Nux vomica                30C
3. Cinchona officinalis tinct.        15C

Treatment Schedule

Doses cited are to be administered on a 3X daily schedule, unless otherwise indicated. Dose usually continued for 2 weeks. Liquid preparations usually use 8-10 drops per dose. Solid preps are usually 3 pellets per dose. Children use 1/2 dose.

Legend

X = 1 to 10 dilution - weak (triturition)
C = 1 to 100 dilution - weak (potency)
M = 1 to 1 million dilution (very strong)
X or C underlined means it is most useful potency

Asterisk (*) = Primary remedy. Means most necessary remedy. There may be more than one remedy - if so, use all of them.

References

Boericke, D.E., 1988. Homeopathic Materia Medica.

Coulter, C.R., 1986. Portraits of Homeopathic Medicines.

Kent, J.T., 1989. Repertory of the Homeopathic Materia Medica.

Koehler, G., 1989. Handbook of Homeopathy.

Shingale, J.N., 1992. Bedside Prescriber.

Smith, Trevor, 1989. Homeopathic Medicine.

Ullman, Dana, 1991. The One Minute (or so) Healer.

Herbal Approaches

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Herbs
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Ginseng
Gotu kola
Horsetail

Note: The misdirected use of an herb can produce severely adverse effects, especially in combination with prescription drugs. This Herbal information is for educational purposes and is not intended as a replacement for medical advice.

Discussion:

Ginseng can be useful in this condition by not only stimulating appetite and energy but also aiding digestion.

Aromatherapy - Essential Oils

Marjoram Essence,Melissa Essence,
Thyme Essence.



Related Health Conditions

Anorexia Nervosa
Appetite disorders

Abstracts

References

Arden, M.R et al.: Alkaline Urine is Associated With Eating Disorders. American Journal of Diseases in Children, January 1991;145:28-30.

Boskind-White, M. & W.C. White. Bulimarexia: The Binge/Purge Cycle. W.W. Norton: New York, 1983.

Bruch, H. Psychotherapy in primary anorexia. J Nervous Mental Disorders, 1970: 150; 51-67.

Dalvitt-McPhillips, S. A dietary approach to bulimia treatment. Physiology Behavior, 1984: 33; 769-775.

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. American Psychiatric Association: Washington, D.C., 1980.

Glassman, A.H. & B.T. Walsh. Link between bulimia and depression. J Clin Psychopharmacology, 1983: 3; 203.

Halmi, K.A. The state of research in anorexia nervosa and bulimia. Psychiatric Developments, 1983: 3; 247-262.

Hawkins, R.C., W.J. Frenouw & P.F. Clement. The Binge-Purge Syndrome: Diagnosis, Treatment and Research. Springer Publ.: NY, 1984, p. 22.

Holden, C. Depression, research advances, treatment lags. Science, 1986: 233; 693-816.

Hsu, L.K. : Treatment of Bulimia Nervosa With Lithium Carbonate: A Controlled Trial. The Journal of Nervous and Mental Disease, 1991;179(6):851-355.

Johnson, R.E. & Sinnot. Bulimia. American Family Physician, 1981: 23; 141-143.

Jonas, J.M., H.G. Pope, & J.I. Hudson. Treatment of bulimia and MAO inhibitors. J Clin Psychopharmacology, 1983: 3; 59-60.

Kopp W et al., Low leptin levels predict amenorrhea in underweight and eating disordered females [see comments]. Mol Psychiatry, 1997 Jul, 2:4, 335-40.

Lautenbacher, S. et al: Diet and Pain Sensitivity: A Validation of Clinical Findings. Physiology and Behavior, 1991;50:629-631.

Lucas, A.R. Pigging out. JAMA, 1982: 82; 242.

Mendels, J. Eating Disorders and antidepressants. Journal Clinical Psycho-pharmacology, 1983: 3; 59.

Milner, R.D. Protein-calorie malnutrition. Present Knowledge in Nutri. Hegsted, D.M., Chichester, D.O., Darby, K.W., McNutt, K.W., Stalvey, R.M. & Stotz, E.H. Nutrition Foundation: Wash, DC, 1976, pp. 428-436.

Pope, H.G., J.I. Hudson, J.M. Jones, et al. Bulimia treated with imipramine: a placebo-controlled double-blind study. Am J Psychiatry, 1983: 140; 554-558.

Pope, Harrison & J.I. Hudson. New Hope for Binge Eaters: Advances in the Understanding and Treatment of Bulimia. Harper & Row: NY, 1984.

Roy-Bryne, P., H. Gwirtsman, C.K. Edelstein, et al. Eating disorders and anti-depressants. J Clin Psychopharmacology, 1983: 3; 60-61.

Walsh, B.T., J. Stewart, L. Wright, et al. Treatment of bulimia and monoamine oxidase inhibitors. Am J Psychiatry, 1982: 139; 1629-1630.

Wooley, S., O. Wooley & S. Dyrenforth. Theoretical, practical, and social issues in behavioral treatments of obesity. J Applied Behavior Analysis, 1980: 35; 151-175.

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