Bulimia Nervosa DSM-5 307.51 (F50.2)
DSM-5 Category: Feeding and Eating Disorders
Individuals diagnosed with bulimia nervosa undertake frequent binge eating, followed by expelling the food, typically by inducing vomiting, but also through exercising and the use of laxative agents, diuretics, and enemas (American Psychiatric Association, 2013). The binge eating occurrences are often prompted by a negative perception of one’s body image, temporarily alleviated by the binge eating episode. Since the individual with bulimia nervosa is overanxious about body weight, purging of the food is viewed as a necessity. This is in contrast to binge eating disorder, which does not involve the purging of food after an excess of food consumption (Bulik et al., 2012). Furthermore, although bulimia nervosa and anorexia nervosa are similar in some respects, the two are in no way identical eating disorders. Patients with anorexia nervosa are generally underweight (Steinglass et al., 2013), whereas bulimia nervosa patients are not necessarily underweight, and are often at a normal body weight (Bulik et al., 2012).
There is no definite age of onset of bulimia nervosa, but it is typically seen in adolescent males and females (Smink et al., 2012). Bulimia nervosa is somewhat more prevalent in females than in males, with 1.3% of females suffering from bulimia nervosa (in a national sample), and .5% of males (Swanson et al., 2011).
Symptoms of Bulimia Nervosa
Bulimia nervosa is associated with various symptoms, detailed by the American Psychiatric Association (2013) and the peer-reviewed literature. Three crucial features that define bulimia nervosa have been articulated (American Psychiatric Association, 2013). These are, firstly, the repeated indulgence in binge eating; secondly, resorting to compensatory behaviors to ameliorate the fear of gaining weight; and thirdly, low self-esteem issues that stem from an unwarranted, critical feeling of one’s body image and weight. There is an additional feature that must be present alongside these symptoms in order for a patient to be diagnosed with bulimia nervosa: any binge eating events followed by compensation needs to be relatively frequent. Specifically, if these events take place at a minimum of one time per week – over a 3 month timespan – then a diagnosis of bulimia nervosa may be made.
Although these are the symptoms that must be present in order for a diagnosis of bulimia nervosa to be made, there are often other symptoms that accompany bulimia nervosa. Signs of psychosis have been found in patients with eating disorders like bulimia nervosa (Miotto et al., 2010). Moreover, those with bulimia nervosa frequently have the feeling that there is something flawed with their mind, and that others are at fault for their problems (Miotto et al., 2010). In addition, there is evidence that a feeling of loneliness is correlated with the occurrence of bulimia nervosa (Levine, 2012), highlighting the psychological dynamics that are at play behind this disorder.
Causes of Bulimia Nervosa: From Genetics to Environment
The environmental and biological mechanisms that underlie bulimia nervosa have been researched in some depth. The principle mechanisms that give rise to bulimia nervosa may be classified into two groups: genetic variables at play and environmental factors that impact the patient.
There is a considerable body of evidence that indicates that bulimia nervosa is largely the result of intrinsic of biological factors in the patient. Genetic research on twins have revealed that there often is a hereditary basis to bulimia nervosa (Trace et al., 2013), and various authors have attempted to uncover the changes in genes that could lead to the onset of this eating disorder. It has been established that faulty expression of brain-derived neurotrophic factors (a growth factor typically expressed in the brain) significantly increases the risk that an individual will be affected by bulimia nervosa (Nakazato et al., 2012). This is consistent with what is known about brain-derived neurotrophic factors: namely, that they are key regulators of food consumption behaviors.
Although biological mechanisms can certainly trigger bulimia nervosa, the role of social and psychological dynamics in contributing to the onset of this disorder cannot be discounted. Patients with bulimia nervosa may be anxious about their body image due to societal pressures that tacitly suggest that being thin is a “good thing.”
Impact of Bulimia Nervosa on Family Relationships
Family environment is a critical factor in many psychiatric disorders, and bulimia nervosa is no exception. For example, in families that emphasize the importance of bodily appearance, there is a skewed view of the individual with an eating disorder (Espíndola and Blay, 2009). A thorough study of how families perceive eating disorders nervosa was undertaken by Espíndola and Blay (2009), and several observations were made by the authors. For instance, many families reported a lack of understanding of the disorder, or that they knew “something was wrong,” but were not certain what it was. Another trend highlighted by this study was that family members often underestimated the consequences of eating disorders like bulimia nervosa. Additionally, once parents understood that their child was suffering from a very real disorder, feelings of guilt and impotence were admitted. Thus, bulimia nervosa can have impacts on the relationships between individuals in a family, and several themes tend to emerge in families with a member who has bulimia nervosa.
Psychotherapy Approaches to Bulimia Nervosa
There are numerous treatment options for those with bulimia nervosa, from fluoxetine and antipsychotics to psychotherapy-based treatments. Psychotherapy is generally regarded as being a more effective means to treat bulimia nervosa than medications (Hay and Claudino, 2012). Of the various psychotherapy approaches that have been tested under different conditions, cognitive behavior therapy (CBT) is perhaps the most efficacious (Hay, 2013). This psychotherapeutic method emphasizes the need to correct detrimental behaviors through the use of specific strategies and actions structured around these behaviors. CBT is a particularly useful treatment option because it does not always require a professional in order to be successful. Wilson and Zandberg (2012) proposed the use of cognitive behavior therapy based on self-help guides that could, in principle, be used with internet platforms, though the authors are careful to note that presently existing self-help guides structured around cognitive behavior therapy are updated and should be revisited. Research into cognitive behavior therapy as a treatment for bulimia nervosa and other eating disorders has been accelerating since this psychotherapy method shows promise as an important means of alleviating the effects of bulimia nervosa.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bulik, C.M., Marcus, M.D., Zerwas, S., Levine, M.D., La Via, M. (2012). The changing "weightscape" of bulimia nervosa. The American Journal of Psychiatry, 169(10), 1031-1036.
Espíndola, C.R., & Blay, S.L. (2009). Family perception of anorexia and bulimia: a systematic review. Revista de saude publica, 43(4), 707-716.
Hay, P. (2013). A systematic review of evidence for psychological treatments in eating disorders: 2005 2012. The Internation Journal of Eating Disorders, 46(5), 462-469.
Hay, P.J., & Claudino, A.M. (2012). Clinical psychopharmacology of eating disorders: a research update. The International Journal of Neuropsychopharmacology, 15(2), 209-222.
Levine, M.P. (2012). Loneliness and eating disorders. Journal of Psychology, 146(1-2), 243-57.
Miotto, P., Pollini, B., Restaneo, A., Favaretto, G., Sisti, D., Rocchi, M.B., Preti, A. (2010). Symptoms of psychosis in anorexia and bulimia nervosa. Psychiatry Research, 175(3), 237-243.
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Swanson, S.A., Crow, S.J., Le Grange, D., Swendsen, J., Merikangas, K.R. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
Trace, S.E., Baker, J.H., Peñas-Lledó, E., Bulik, C.M. (2013). The genetics of eating disorders. Annual Review of Clinical Psychology, 9, 589-620.
Wilson, G.T., & Zandberg, L.J. (2012). Cognitive-behavioral guided self-help for eating disorders: effectiveness and scalability. Clinical Psychology Review, 32(4), 343-357.
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