Though still uncommon, bulimia is not as rare as anorexia. Doctors estimate that it occurs in as many as five percent of adolescent and young adult women. Only 10 to 15 percent of bulimics are male. Of the three eating disorders, it is the one most easily kept hidden, since many bulimics maintain a normal body weight, even while they engage in the extreme and destructive bingeing and purging that characterizes the disease. As a result, the actual number of bulimics may be twice as high as the estimates.
- Warning Signs of Bulimia
- The High Cost of Bulimia
- What Qualifies as True Bulimia
- What Happens to Your Mind and Body
- Getting Treatment for Bulimia
In the past couple of decades, some of the secrecy cloaking bulimia has been brushed aside as celebrity confessions and widespread media reports about the disorder have multiplied. Many colleges now have programs through their student health centers to deal specifically with bulimia, since it is so widespread on campuses. Some studies claim that 10 to 20 percent of female college students have practiced bulimic behavior at some time in their lives. Like anorexia, bulimia is also associated with certain athletic and artistic pursuits, such as running, gymnastics, competitive swimming, and dancing.
The causes of bulimia are not well understood. A history of anorexia may be a risk factor. Early warning signs include abnormal concerns related to weight, withdrawal and social isolation, negative changes in body image and self- image, and changes in relationships with family and peers. When bulimics review their early years, they report more intrusive parental behavior than people without eating disorders. And a study of European adolescents found that bulimic behavior is associated with early onset of menstruation and early sexual experiences.
Cultural and psychological factors also play a role, and there may be a chemical imbalance at work as well. A recent study found an association between bulimic behavior and a deficiency of tryptophan in the body. Tryptophan, a naturally occurring amino acid found in many foods, is used to make serotonin, which has a role in regulating appetite. Bulimics have also been found to have lower than normal levels of leptin, a protein that inhibits food intake. Genetics may also be a culprit. A study of 1900 fraternal and identical twins concluded that bulimia is often inherited. Work is ongoing to locate the genes at fault.
Bulimics may consume astounding quantities of food in the binge phase of their cycle. A typical binge lasts about two hours. The following description from "My Name is Caroline" (Doubleday, 1988), a book by recovering bulimic Caroline Miller, vividly illustrates what was a characteristic binge for the author, and many other bulimics:
...I give my order for a double-thick vanilla frappe.... Colorful jimmies, peanuts, chocolate chips, coconut and other ice cream accouterments beckoned. I wanted to ask the woman to toss some jimmies and chocolate chips into my shake, but I knew that normal people didn't do that kind of thing....[At] my next destination, David's Cookies,...I quickly picked out two pounds of cookies. I crammed a few cookies in my mouth while I paid....Baskin Robbins was next....I ordered a mixture of pralines 'n cream and jamoca almond fudge....With the cookies in my pocket I was going to make a huge crunchy mess and finish it all myself.
Ms. Miller then describes her purge, a graphic, unpleasant, but accurate portrayal of what a bulimic goes through:
I jammed two fingers down my throat and felt the familiar bile rising. Harder and harder I thrust, gouging the back of my throat in the process....All of a sudden the food came up in gushes, splattering all over the toilet seat, the floor and my clothes. Disgusted yet elated at my success, I kept probing, trying to make sure I was getting everything up....
What Qualifies as True Bulimia
To be diagnosed as a bulimic, you must meet the following diagnostic criteria:
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You engage in recurrent episodes of binge-eating. This is defined as consuming larger than normal amounts of food within a two-hour period, and feeling a lack of control over eating during the episode.
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You repeatedly compensate for the binge-eating with purging behavior to prevent weight gain. Purging behavior can include self-induced vomiting; misuse of laxatives, diuretics, enemas, over-the-counter diet pills, or other medications; fasting; or excessive exercise.
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You binge and purge at least twice a week for three months.
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Your self-evaluation is unreasonably influenced by body shape and weight.
It is important to remember that while these precise standards must be met for a medical diagnosis, you may be one of many people who does not meet the strict criteria but is still moderately to severely impaired by bulimic behavior.
What Happens to Your Mind and Body
Bulimia, too, has both psychological and physical components, including its own set of personality characteristics. Researchers have suggested that many bulimics suffer low self-esteem, intolerance of frustration, and an inability to appropriately recognize and express their feelings. Some have even theorized that childhood sexual abuse may be a factor in later development of bulimia, but this link has never been proved, and is certainly not the case for all bulimics.
Like anorexics, bulimics are likely to be preoccupied with food, at the expense of other, healthier pursuits. Their obsessiveness and secretiveness is comparable to the behavior of many substance abusers. In fact, bulimia has been linked to substance abuse, and other impulsive actions such as overspending, shoplifting, and promiscuity. The hidden nature of a bulimic's bingeing and purging activities can lead to social isolation, although many bulimics manage to function appropriately and keep their behavior secret.
Depression has also been associated with bulimia, and some studies have found that more than half of all bulimics have experienced clinical depression. However, it is unclear whether depression causes the eating disorder, or vice versa.
Some research has also found irregularities in the brain chemistry of bulimics, particularly in the release and processing of the chemicals that regulate the feeling of being full. While most people eat only when hungry, bulimics respond to the mere presence of food.
Bulimia can remain hidden for years, while the bulimic persists in her unhealthy eating habits. Eventually, however, physical signs of the disease are likely to become difficult to conceal. Extreme purging can cause dehydration and imbalances in the body's level of potassium, sodium, and other chemicals, which in turn can lead to fatigue, seizures, irregular heartbeat, and brittle bones.
Vomiting, the most commonly used method of purging, can also lead to tell-tale signsand even serious injury:
- It can damage the stomach and the esophagus, sometimes resulting in bleeding, ulcers, loss of the gag reflex, and chronic heartburn.
- Stomach acids can have very damaging effects on the mouth. They cause gums to recede and tooth enamel to erode, leading to ragged teeth. Tooth enamel is not replaceable, and some bulimics finally need to have all their teeth extracted.
- Repeated vomiting also causes salivary glands to swell, resulting in a chipmunk-like appearance.
- Many bulimics have abrasions and scarring on the back of the hands, caused when they stick their fingers down their throats to induce vomiting.
Overusing laxatives results in a different set of problems. Constipation and bloating are common, and laxative abuse may also lead to bowel abnormalities and rectal bleeding.
Bulimics are usually more willing than anorexics to admit their problem and accept help. The disorder is generally considered less complicated to treat than anorexia, and bulimics rarely need hospitalization. Exceptions are cases of extreme chemical imbalances, serious gastrointestinal complications, or severe depression.
Cognitive behavioral therapy that helps you reevaluate unrealistic expectations and demands on yourself is usually regarded as most effective in treating bulimia, with quicker and more dependable results than psychotherapy. One technique is to keep a diary of food consumption and eating behavior. For example, your therapist may have you write down everything you eat over a certain time perioda chore that can very effectively interrupt a pattern of bingeing.
Cognitive therapy also helps you recognize what triggers your binge/purge behavior and helps you come up with other ways to deal with those triggers. It also helps you deal with the unrealistic messages about body image that permeate our culture. Therapy should be combined with nutritional counseling, to help you learn how to plan regular, balanced meals.
Group therapy can also work well, particularly for those in college. Family therapy is often helpful if you live at home. Even light therapy can help, according to one recent study of bulimics with seasonal affective disorder, a condition that often accompanies the problem.
Antidepressant medication can be very beneficial if you are one of the many bulimics who suffer from a depressive disorder. A variety of these drugs have been used with bulimics and doctors are currently enthusiastic about fluoxetine (Prozac), which boosts levels of serotonin, one of the brain chemicals that controls feelings of being full. Studies have shown fluoxetine to be effective in patients who have failed to respond to or have relapsed after cognitive behavioral therapy or psychotherapy. In 1997, the drug became the first to be specifically approved for the treatment of bulimia. Other drugs that have been used successfully include desipramine (Norpramin), imipramine (Tofranil), and trazodone (Desyrel).
Regular dental care is also an important part of treatment for bulimics.
Like anorexics, bulimics are prone to relapse. The episodes can be caused by stressful life events, anything from final exams to career change to divorce. Some kind of continuing therapy or access to a support or self-help group can often prevent relapse, or make it easier to quickly move through the relapse back to healthy eating patterns. Forty percent of binge-eaters are male.
