Bulimia nervosa
Encyclopedia
Bulimia nervosa is an eating disorder
characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging (vomiting) and/or by laxative
, diuretics or excessive exercise. Bulimia nervosa is nine times more likely to occur in women than men (Barker 2003). Antidepressants, especially SSRIs, are widely used in the treatment of bulimia nervosa. (Newell and Gournay 2000).
The term bulimia comes from Greek βουλιμία (boulīmia; ravenous hunger), a compound of βους (bous), ox + λιμός (līmos), hunger. Bulimia nervosa was named and first described by the British psychiatrist Gerald Russell
in 1979.
Bulimia is strongly familial. Twin studies estimate the heritability of syndromic bulimia to be 54 to 83%.
The frequent contact between teeth and gastric acid
, in particular, may cause:
As with many psychiatric illnesses, delusions can occur with other signs and symptoms leaving the person with a false belief that is not ordinarily accepted by others.
The person may also suffer physical complications such as tetany, epileptic seizures, cardiac arrhythmias and muscle weakness.(ICD-10).
People with bulimia nervosa may also exercise to a point that excludes other activities.
, such as depression
or general anxiety disorder
: A 1985 Columbia University
study on female bulimics at New York State Psychiatric Institute
found 70% had suffered depression some time in their lives (as opposed to 25.8% for adult females in a control sample from the general population), rising to 88% for all affective disorders combined. Another study by the Royal Children's Hospital
in Melbourne
on a cohort
of 2000 adolescents similarly found that those meeting at least two of the DSM-IV
criteria for bulimia nervosa or anorexia nervosa
had a sixfold increase in risk of anxiety and a doubling of risk for substance dependency.
Bulimia also has negative effects on the sufferer's dental health due to the acid passed through the mouth from frequent vomiting causing acid erosion, mainly on the posterior dental surface.
According to Barker, "persons with bulimia are more able to live and interact in everyday chores and tasks such as work and having relationships without the condition overly affecting their abilities".
Bulimia nervosa can be difficult to detect, compared to anorexia nervosa
, because bulimics tend to be of average or slightly above or below average weight. Many bulimics may also engage in significantly disordered eating and exercising patterns without meeting the full diagnostic criteria for bulimia nervosa. The diagnostic criteria utilized by the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV TR) published by the American Psychiatric Association
includes repetitive episodes of binge eating (a discrete episode of overeating during which the individual feels out of control of consumption) compensated for by excessive or inappropriate measures taken to avoid gaining weight. The diagnosis is made only when the behavior is not a part of the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on physical mass or appearance.
There are two sub-types of bulimia nervosa:
, fluoxetine
, lithium carbonate, nomifensine, trazodone, and bupropion. Research groups who have seen a relationship to seizure disorders have attempted treatment with phenytoin, carbamazepine, and valproic acid. Opiate antagonists naloxone and naltrexone, which block cravings for gambling, have also been used.
There has also been some research characterizing bulimia nervosa as an addiction disorder, and limited clinical use of topiramate
, which blocks cravings for opiates, cocaine, alcohol and food.
Maudsley Family Therapy
a.k.a. Family Based Treatment (FBT), developed at the Maudsley Hospital in London
for the treatment of anorexia nervosa (AN) has been shown to have positive results for the treatment of bulimia nervosa. FBT has been shown through empirical
research to be the most efficacious treatment of AN for patients under the age of eighteen and within three years of onset of illness. The studies to date using FBT to treat BN have been promising.
Some researchers have also claimed positive outcomes in hypnotherapy
treatment.
The Twelve-Step model ,used for chemically dependent individuals, was applied to bulimic patients with good results. Researchers at [Ohio State University], in a preliminary study, incorporated the twelve-step model in their treatment of bulimic women in an inpatient unit. They reported positive outcomes.
found the self-reported incidence of purging rose from 0% in 1995 (a few weeks after the introduction of television in the province) to 11.3% in 1998.
Brain-derived neurotrophic factor
(BDNF) is under investigation as a possible mechanism.
Through the cognitive and socio-cultural perspectives, indications towards the origin of bulimia nervosa can be established. Fairburn et al’s cognitive behavioral model of bulimia nervosa provides a chief indication of the cause of bulimia through a cognitive perspective, while the “thin ideal” is particularly responsible for the etiology of bulimia nervosa through a socio-cultural context.
When attempting to decipher the origin of bulimia nervosa in a cognitive context, Fairburn and et al’s cognitive behavioral model is often considered the golden standard. Fairburn et al’s model discusses the process in which an individual falls into the binge-purge cycle and thus develops bulimia. Fairburn et al argue that extreme concern with weight and shape coupled with low self esteem will result in strict, rigid, and inflexible dietary rules. Accordingly, this would lead to unrealistic restricted eating, which may consequently induce an eventual “slip” where the individual commits a minor infraction of the strict and inflexible dietary rules. Moreover, the cognitive distortion due to dichotomous thinking leads the individual to binge. The binge subsequently should trigger a perceived loss of control, promoting the individual to purge in hope of counteracting the binge. However, Fairburn et al assert the cycle repeats itself, and thus consider the binge-purge cycle to be self-perpetuating.
In contrast, Byrne and Mclean’s findings differed slightly from Fairburn et al’s cognitive behavioral model of bulimia nervosa in that the drive for thinness was the major cause of purging as a way of controlling weight. In turn, Byrne and Mclean argued that this makes the individual vulnerable to binging, indicating that it is not a binge-purge cycle but rather a purge-binge cycle in that purging comes before binging. Similarly, Fairburn et al’s cognitive behavioral model of bulimia nervosa is not necessarily applicable to every individual and is certainly reductionist. Everyone differs from another, and taking such a complex behavior like bulimia and applying the same one theory to everyone would certainly be invalid. In addition, the cognitive behavioral model of bulimia nervosa is very cultural bound in that it may not be necessarily applicable to cultures outside of the Western society. To evaluate, Fairburn et al’s model and more generally the cognitive explanation of bulimia nervosa is more descriptive than explanatory, as it does not necessarily explain how bulimia arises. Furthermore, it is difficult to ascertain cause and effect, because it may be that distorted eating leads to distorted cognition rather than vice versa.
When exploring the etiology of bulimia through a socio-cultural perspective, the “thin ideal internalization” is significantly responsible. The thin ideal internalization is the extent to which individuals adapt to the societal ideals of attractiveness. Individuals first accept and “buy into” the ideals, and then attempt to transform themselves in order to reflect the societal ideals of attractiveness. J. Kevin Thompson and Eric Stice claim that family, peers, and most evidently media reinforce the thin ideal, which may lead to an individual accepting and “buying into” the thin ideal. In turn, Thompson and Stice assert that if the thin ideal is accepted, one could begin to feel uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal set out by society. Thus, people feeling uncomfortable with their bodies may result in suffering from body dissatisfaction, and may develop a certain drive for thinness. Consequently, body dissatisfaction coupled with drive for thinness is thought to promote dieting and negative affects, which could eventually lead to bulimic symptoms such as purging or binging. Binges lead to self-disgust which causes purging to prevent weight gain.
A study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is Thompson’s and Stice’s research. The aim of their study was to investigate how and to what degree does media effect the thin ideal internalization. Thompson and Stice used randomized experiments (more specifically programs) dedicated to teaching young women how to be more critical when it comes to media, in order to reduce thin ideal internalization. The results showed that by creating more awareness of the media’s control of the societal ideal of attractiveness, the thin ideal internalization significantly dropped. In other words, less thin ideal images portrayed by the media resulted in less thin ideal internalization. Therefore, Thompson and Stice concluded that media effected greatly the thin ideal internalization.
There are higher rates of eating disorder
s in groups involved in activities which idealize a slim physique, such as dance
, gymnastics
, modeling, cheerleading
, running, acting, rowing and figure skating
. Bulimia is more prevalent among Caucasian
s.
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging (vomiting) and/or by laxative
Laxative
Laxatives are foods, compounds, or drugs taken to induce bowel movements or to loosen the stool, most often taken to treat constipation. Certain stimulant, lubricant, and saline laxatives are used to evacuate the colon for rectal and/or bowel examinations, and may be supplemented by enemas under...
, diuretics or excessive exercise. Bulimia nervosa is nine times more likely to occur in women than men (Barker 2003). Antidepressants, especially SSRIs, are widely used in the treatment of bulimia nervosa. (Newell and Gournay 2000).
The term bulimia comes from Greek βουλιμία (boulīmia; ravenous hunger), a compound of βους (bous), ox + λιμός (līmos), hunger. Bulimia nervosa was named and first described by the British psychiatrist Gerald Russell
Gerald Russell
Professor Gerald Francis Morris Russell is a British psychiatrist. In 1979 he published the first description of bulimia nervosa, and Russell's sign has been named after him.-Early life:...
in 1979.
Bulimia is strongly familial. Twin studies estimate the heritability of syndromic bulimia to be 54 to 83%.
Signs and symptoms
These cycles often involve rapid and out-of-control eating, which may stop when the bulimic is interrupted by another person or the stomach hurts from overextension, followed by self-induced vomiting or other forms of purging. This cycle may be repeated several times a week or, in more serious cases, several times a day, and may directly cause:- Chronic gastric reflux after eating
- DehydrationDehydrationIn physiology and medicine, dehydration is defined as the excessive loss of body fluid. It is literally the removal of water from an object; however, in physiological terms, it entails a deficiency of fluid within an organism...
and hypokalemiaHypokalemiaHypokalemia or hypokalaemia , also hypopotassemia or hypopotassaemia , refers to the condition in which the concentration of potassium in the blood is low...
caused by frequent vomiting - Electrolyte imbalance, which can lead to cardiac arrhythmia, cardiac arrestCardiac arrestCardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
, and even death - EsophagitisEsophagitisEsophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
, or inflammationInflammationInflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the esophagusEsophagusThe esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach... - Boerhaave syndromeBoerhaave syndromeEsophageal rupture is rupture of the esophageal wall due to vomiting. 56% of esophageal perforations are iatrogenic, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery...
, a rupture in the esophageal wall due to vomiting - Oral traumaPhysical traumaTrauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
, in which repetitive insertion of fingers or other objects causes lacerations to the lining of the mouth or throat - GastroparesisGastroparesisGastroparesis, also called delayed gastric emptying, is a medical condition consisting of a paresis of the stomach, resulting in food remaining in the stomach for a longer period of time than normal. Normally, the stomach contracts to move food down into the small intestine for digestion. The...
or delayed emptying - ConstipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
- InfertilityInfertilityInfertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term...
- Enlarged glands in the neck, under the jaw line
- Peptic ulcers
- CallusCallusA callus is an especially toughened area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation. Rubbing that is too frequent or forceful will cause blisters rather than allow calluses to form. Since repeated contact is required, calluses...
es or scarsRussell's signRussell's sign named after British psychiatrist Gerald Russell is a sign defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time...
on back of hands due to repeated trauma from incisors - Constant weight fluctuations are common
The frequent contact between teeth and gastric acid
Gastric acid
Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...
, in particular, may cause:
- Severe dental erosion
- Perimolysis, or the erosion of tooth enamel
- Swollen salivary glandSalivary glandThe salivary glands in mammals are exocrine glands, glands with ducts, that produce saliva. They also secrete amylase, an enzyme that breaks down starch into maltose...
s
As with many psychiatric illnesses, delusions can occur with other signs and symptoms leaving the person with a false belief that is not ordinarily accepted by others.
The person may also suffer physical complications such as tetany, epileptic seizures, cardiac arrhythmias and muscle weakness.(ICD-10).
People with bulimia nervosa may also exercise to a point that excludes other activities.
Related disorders
Bulimics are much more likely than non-bulimics to have an affective disorderAffective spectrum
The affective spectrum is a grouping of related psychiatric and medical disorders which may accompany bipolar, unipolar, and schizoaffective disorders at statistically higher rates than would normally be expected. These disorders are identified by a common positive response to the same types of...
, such as depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
or general anxiety disorder
General anxiety disorder
Generalized anxiety disorder is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry...
: A 1985 Columbia University
Columbia University
Columbia University in the City of New York is a private, Ivy League university in Manhattan, New York City. Columbia is the oldest institution of higher learning in the state of New York, the fifth oldest in the United States, and one of the country's nine Colonial Colleges founded before the...
study on female bulimics at New York State Psychiatric Institute
New York State Psychiatric Institute
The New York State Psychiatric Institute, established in 1895 and located on Riverside Drive at the foot of Washington Heights, the far upper west side of Manhattan in New York City, was one of the first institutions in the United States to integrate teaching, research and therapeutic approaches to...
found 70% had suffered depression some time in their lives (as opposed to 25.8% for adult females in a control sample from the general population), rising to 88% for all affective disorders combined. Another study by the Royal Children's Hospital
Royal Children's Hospital
The Royal Children's Hospital is a major children's hospital in Melbourne, Australia.As the major paediatric hospital in Victoria, the Royal Children's Hospital and offers a full range of clinical services, tertiary care and health promotion and prevention programs for children and adolescents...
in Melbourne
Melbourne
Melbourne is the capital and most populous city in the state of Victoria, and the second most populous city in Australia. The Melbourne City Centre is the hub of the greater metropolitan area and the Census statistical division—of which "Melbourne" is the common name. As of June 2009, the greater...
on a cohort
Cohort (statistics)
In statistics and demography, a cohort is a group of subjects who have shared a particular time together during a particular time span . Cohorts may be tracked over extended periods in a cohort study. The cohort can be modified by censoring, i.e...
of 2000 adolescents similarly found that those meeting at least two of the DSM-IV
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
criteria for bulimia nervosa or anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
had a sixfold increase in risk of anxiety and a doubling of risk for substance dependency.
Bulimia also has negative effects on the sufferer's dental health due to the acid passed through the mouth from frequent vomiting causing acid erosion, mainly on the posterior dental surface.
Diagnosis
The onset of bulimia nervosa is often during adolescence, between 13 and 20 years of age, and many cases have previously suffered obesity, with many sufferers relapsing in adulthood into episodic binging and purging even after initially successful treatment and remission.According to Barker, "persons with bulimia are more able to live and interact in everyday chores and tasks such as work and having relationships without the condition overly affecting their abilities".
Bulimia nervosa can be difficult to detect, compared to anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
, because bulimics tend to be of average or slightly above or below average weight. Many bulimics may also engage in significantly disordered eating and exercising patterns without meeting the full diagnostic criteria for bulimia nervosa. The diagnostic criteria utilized by the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM-IV TR) published by the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
includes repetitive episodes of binge eating (a discrete episode of overeating during which the individual feels out of control of consumption) compensated for by excessive or inappropriate measures taken to avoid gaining weight. The diagnosis is made only when the behavior is not a part of the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on physical mass or appearance.
There are two sub-types of bulimia nervosa:
- Purging type bulimics self-induce vomitingVomitingVomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
(usually by triggering the gag reflexGag reflexThe pharyngeal reflex or gag reflex is a reflex contraction of the back of the throat, evoked by touching the soft palate or sometimes the back of the tongue. It prevents something from entering the throat except as part of normal swallowing and helps prevent choking...
or ingesting emetics such as syrup of ipecacSyrup of ipecacSyrup of ipecac , commonly referred to as ipecac, is derived from the dried rhizome and roots of the ipecacuanha plant, and is a well known emetic .-Preparation:...
) to rapidly remove food from the body before it can be digested, or use laxatives, diuretics, or enemas. - Non-purging type bulimics (approximately 6%–8% of cases) exercise or fast excessively after a binge to offset the caloric intake after eating. Purging-type bulimics may also exercise or fast, but as a secondary form of weight control.
Pharmacological
Some researchers have hypothesized a relationship to mood disorders and clinical trials have been conducted with tricyclic antidepressants, MAO inhibitors, mianserinMianserin
Mianserin is a psychoactive drug of the tetracyclic antidepressant chemical class which is classified as a noradrenergic and specific serotonergic antidepressant and has antidepressant, anxiolytic, hypnotic, antiemetic, orexigenic, and antihistamine effects...
, fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, lithium carbonate, nomifensine, trazodone, and bupropion. Research groups who have seen a relationship to seizure disorders have attempted treatment with phenytoin, carbamazepine, and valproic acid. Opiate antagonists naloxone and naltrexone, which block cravings for gambling, have also been used.
There has also been some research characterizing bulimia nervosa as an addiction disorder, and limited clinical use of topiramate
Topiramate
Topiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
, which blocks cravings for opiates, cocaine, alcohol and food.
Psychotherapy
There are several empirically-supported psychosocial treatments for bulimia nervosa. Cognitive behavioral therapy (CBT), which involves teaching clients to challenge automatic thoughts and engage in behavioral experiments (for example, in session eating of "forbidden foods") has demonstrated efficacy both with and without concurrent antidepressant medication. Research suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic treatment for bulimia nervosa. One exception was a study that suggested that interpersonal psychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects. By using CBT patients record how much food they eat and periods of vomiting with the purpose of identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular basis (Gelder, Mayou and Geddes 2005). Barker (2003) states that research has found 40-60% of patients using cognitive behaviour therapy to become symptom free. He states in order for the therapy to work, all parties must work together to discuss, record and develop coping strategies. Barker (2003) claims by making people aware of their actions they will think of alternatives. Researchers have also reported some positive outcomes for interpersonal psychotherapy and dialectical behavior therapy.Maudsley Family Therapy
Maudsley Family Therapy
Maudsley Family Therapy, also known as Family-Based Treatment or the Maudsley Approach, is a family therapy devised by Christopher Dare and colleagues at the Maudsley Hospital in London in 1985. It was originally intended for the treatment of anorexia nervosa in adolescents under the age of 18 in...
a.k.a. Family Based Treatment (FBT), developed at the Maudsley Hospital in London
London
London is the capital city of :England and the :United Kingdom, the largest metropolitan area in the United Kingdom, and the largest urban zone in the European Union by most measures. Located on the River Thames, London has been a major settlement for two millennia, its history going back to its...
for the treatment of anorexia nervosa (AN) has been shown to have positive results for the treatment of bulimia nervosa. FBT has been shown through empirical
Empirical
The word empirical denotes information gained by means of observation or experimentation. Empirical data are data produced by an experiment or observation....
research to be the most efficacious treatment of AN for patients under the age of eighteen and within three years of onset of illness. The studies to date using FBT to treat BN have been promising.
Some researchers have also claimed positive outcomes in hypnotherapy
Hypnotherapy
Hypnotherapy is a therapy that is undertaken with a subject in hypnosis.The word "hypnosis" is an abbreviation of James Braid's term "neuro-hypnotism", meaning "sleep of the nervous system"....
treatment.
The Twelve-Step model ,used for chemically dependent individuals, was applied to bulimic patients with good results. Researchers at [Ohio State University], in a preliminary study, incorporated the twelve-step model in their treatment of bulimic women in an inpatient unit. They reported positive outcomes.
Etiology
Media portrayals of an 'ideal' body shape are widely considered to be a contributing factor to bulimia (Barker 2003). A survey of 15–18 year-old high school girls in Nadroga, FijiFiji
Fiji , officially the Republic of Fiji , is an island nation in Melanesia in the South Pacific Ocean about northeast of New Zealand's North Island...
found the self-reported incidence of purging rose from 0% in 1995 (a few weeks after the introduction of television in the province) to 11.3% in 1998.
Brain-derived neurotrophic factor
Brain-derived neurotrophic factor
Brain-derived neurotrophic factor, also known as BDNF, is a protein that, in humans, is encoded by the BDNF gene. BDNF is a member of the "neurotrophin" family of growth factors, which are related to the canonical "Nerve Growth Factor", NGF...
(BDNF) is under investigation as a possible mechanism.
Through the cognitive and socio-cultural perspectives, indications towards the origin of bulimia nervosa can be established. Fairburn et al’s cognitive behavioral model of bulimia nervosa provides a chief indication of the cause of bulimia through a cognitive perspective, while the “thin ideal” is particularly responsible for the etiology of bulimia nervosa through a socio-cultural context.
When attempting to decipher the origin of bulimia nervosa in a cognitive context, Fairburn and et al’s cognitive behavioral model is often considered the golden standard. Fairburn et al’s model discusses the process in which an individual falls into the binge-purge cycle and thus develops bulimia. Fairburn et al argue that extreme concern with weight and shape coupled with low self esteem will result in strict, rigid, and inflexible dietary rules. Accordingly, this would lead to unrealistic restricted eating, which may consequently induce an eventual “slip” where the individual commits a minor infraction of the strict and inflexible dietary rules. Moreover, the cognitive distortion due to dichotomous thinking leads the individual to binge. The binge subsequently should trigger a perceived loss of control, promoting the individual to purge in hope of counteracting the binge. However, Fairburn et al assert the cycle repeats itself, and thus consider the binge-purge cycle to be self-perpetuating.
In contrast, Byrne and Mclean’s findings differed slightly from Fairburn et al’s cognitive behavioral model of bulimia nervosa in that the drive for thinness was the major cause of purging as a way of controlling weight. In turn, Byrne and Mclean argued that this makes the individual vulnerable to binging, indicating that it is not a binge-purge cycle but rather a purge-binge cycle in that purging comes before binging. Similarly, Fairburn et al’s cognitive behavioral model of bulimia nervosa is not necessarily applicable to every individual and is certainly reductionist. Everyone differs from another, and taking such a complex behavior like bulimia and applying the same one theory to everyone would certainly be invalid. In addition, the cognitive behavioral model of bulimia nervosa is very cultural bound in that it may not be necessarily applicable to cultures outside of the Western society. To evaluate, Fairburn et al’s model and more generally the cognitive explanation of bulimia nervosa is more descriptive than explanatory, as it does not necessarily explain how bulimia arises. Furthermore, it is difficult to ascertain cause and effect, because it may be that distorted eating leads to distorted cognition rather than vice versa.
When exploring the etiology of bulimia through a socio-cultural perspective, the “thin ideal internalization” is significantly responsible. The thin ideal internalization is the extent to which individuals adapt to the societal ideals of attractiveness. Individuals first accept and “buy into” the ideals, and then attempt to transform themselves in order to reflect the societal ideals of attractiveness. J. Kevin Thompson and Eric Stice claim that family, peers, and most evidently media reinforce the thin ideal, which may lead to an individual accepting and “buying into” the thin ideal. In turn, Thompson and Stice assert that if the thin ideal is accepted, one could begin to feel uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal set out by society. Thus, people feeling uncomfortable with their bodies may result in suffering from body dissatisfaction, and may develop a certain drive for thinness. Consequently, body dissatisfaction coupled with drive for thinness is thought to promote dieting and negative affects, which could eventually lead to bulimic symptoms such as purging or binging. Binges lead to self-disgust which causes purging to prevent weight gain.
A study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is Thompson’s and Stice’s research. The aim of their study was to investigate how and to what degree does media effect the thin ideal internalization. Thompson and Stice used randomized experiments (more specifically programs) dedicated to teaching young women how to be more critical when it comes to media, in order to reduce thin ideal internalization. The results showed that by creating more awareness of the media’s control of the societal ideal of attractiveness, the thin ideal internalization significantly dropped. In other words, less thin ideal images portrayed by the media resulted in less thin ideal internalization. Therefore, Thompson and Stice concluded that media effected greatly the thin ideal internalization.
Epidemiology
There is little data on the prevalence of bulimia nervosa in-the-large, on general populations. Most studies conducted thus far have been on convenience samples from hospital patients, high school or university students. These have yielded a wide range of results: between 0.1% and 1.4% of males, and between 0.3% and 9.4% of females. Studies on time trends in the prevalence of bulimia nervosa have also yielded inconsistent results. According to Gelder, Mayou and Geddes (2005) bulimia nervosa is prevalent between 1 and 2 per cent of women aged 15–40 years. Bulimia nervosa occurs more frequently in developed countries (Gelder, Mayou and Geddes 2005).| Country | Year | Sample size and type | Incidence | |
|---|---|---|---|---|
| Australia Australia Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area... |
2008 | 1,943 adolescents (ages 15–17) | 1.0% male | 6.4% female |
| Portugal Portugal Portugal , officially the Portuguese Republic is a country situated in southwestern Europe on the Iberian Peninsula. Portugal is the westernmost country of Europe, and is bordered by the Atlantic Ocean to the West and South and by Spain to the North and East. The Atlantic archipelagos of the... |
2006 | 2,028 high school students | 0.3% female | |
| Brazil Brazil Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people... |
2004 | 1,807 students (ages 7–19) | 0.8% male | 1.3% female |
| Spain Spain Spain , officially the Kingdom of Spain languages]] under the European Charter for Regional or Minority Languages. In each of these, Spain's official name is as follows:;;;;;;), is a country and member state of the European Union located in southwestern Europe on the Iberian Peninsula... |
2004 | 2,509 female adolescents (ages 13–22) | 1.4% female | |
| Hungary Hungary Hungary , officially the Republic of Hungary , is a landlocked country in Central Europe. It is situated in the Carpathian Basin and is bordered by Slovakia to the north, Ukraine and Romania to the east, Serbia and Croatia to the south, Slovenia to the southwest and Austria to the west. The... |
2003 | 580 Budapest Budapest Budapest is the capital of Hungary. As the largest city of Hungary, it is the country's principal political, cultural, commercial, industrial, and transportation centre. In 2011, Budapest had 1,733,685 inhabitants, down from its 1989 peak of 2,113,645 due to suburbanization. The Budapest Commuter... residents |
0.4% male | 3.6% female |
| Australia Australia Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area... |
1998 | 4,200 high school students | 0.3% combined | |
| USA | 1996 | 1,152 college students | 0.2% male | 1.3% female |
| Norway Norway Norway , officially the Kingdom of Norway, is a Nordic unitary constitutional monarchy whose territory comprises the western portion of the Scandinavian Peninsula, Jan Mayen, and the Arctic archipelago of Svalbard and Bouvet Island. Norway has a total area of and a population of about 4.9 million... |
1995 | 19,067 psychiatric patients | 0.7% male | 7.3% female |
| Canada Canada Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean... |
1995 | 8,116 (random sample) | 0.1% male | 1.1% female |
| Japan Japan Japan is an island nation in East Asia. Located in the Pacific Ocean, it lies to the east of the Sea of Japan, China, North Korea, South Korea and Russia, stretching from the Sea of Okhotsk in the north to the East China Sea and Taiwan in the south... |
1995 | 2,597 high school students | 0.7% male | 1.9% female |
| USA | 1992 | 799 college students | 0.4% male | 5.1% female |
There are higher rates of eating disorder
Eating disorder
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s in groups involved in activities which idealize a slim physique, such as dance
Dance
Dance is an art form that generally refers to movement of the body, usually rhythmic and to music, used as a form of expression, social interaction or presented in a spiritual or performance setting....
, gymnastics
Gymnastics
Gymnastics is a sport involving performance of exercises requiring physical strength, flexibility, agility, coordination, and balance. Internationally, all of the gymnastic sports are governed by the Fédération Internationale de Gymnastique with each country having its own national governing body...
, modeling, cheerleading
Cheerleading
Cheerleading is a physical activity, sometimes a competitive sport, based on organized routines, usually ranging from one to three minutes, which contain the components of tumbling, dance, jumps, cheers, and stunting to direct spectators of events to cheer on sports teams at games or to participate...
, running, acting, rowing and figure skating
Figure skating
Figure skating is an Olympic sport in which individuals, pairs, or groups perform spins, jumps, footwork and other intricate and challenging moves on ice skates. Figure skaters compete at various levels from beginner up to the Olympic level , and at local, national, and international competitions...
. Bulimia is more prevalent among Caucasian
Caucasian race
The term Caucasian race has been used to denote the general physical type of some or all of the populations of Europe, North Africa, the Horn of Africa, Western Asia , Central Asia and South Asia...
s.
See also
- Anorectic Behavior Observation ScaleAnorectic Behavior Observation ScaleThe Anorectic Behavior Observation Scale is a thirty-item diagnostic questionnaire devised to be answered by the parents, spouse or other family member of an individual suspected of having an eating disorder. It was developed by Vandereyken et al. in 1992. The questions address three factors;...
- Anti-fat biasAnti-fat biasAnti-fat bias refers to the prejudicial assumption of personality characteristics based on a visual assessment of a person as suffering from obesity based on physical characteristics...
- Anorexia nervosaAnorexia nervosaAnorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
- Eating RecoveryEating RecoveryEating recovery refers to the full spectrum of care that acknowledges and treats the multiple etiologies of anorexia nervosa and bulimia, including the biological, psychological, social and emotional/spiritual causes of the disorder, through a comprehensive, integrated treatment regimen...