In the modern Western societies, young females become increasingly more preoccupied with their body shape and develop a distorted body image, which implies the desire to regularly improve the perceived “fitness”. Therefore, eating disorders such as anorexia nervosa and bulimia nervosa have been spreading over the last forty years, and in year 2003, the prevalence of bulimia nervosa was estimated in British community studies at between 0.5 and 1 percent depending on the social class and racial structure (Hay & Bacaltchuk, 2003). In young female samples, the prevalence rises to 1-7 percent (European countries) (Lam & Lee, 2004). The present literature review is intended to clarify the causes, diagnosis and treatment practices for bulimia nervosa as well as ethical and social considerations in diagnosis and treatment.
Causes and diagnosis of bulimia nervosa
According to Hay and Bacaltchuk, bulimia nervosa is defined as “an intense preoccupation with body weight and shape, with regular episodes of uncontrolled overeating of large amounts of food (binge eating) associated with use of extreme methods to counteract the feared effects of overeating” (Hay & Bacaltchuk, 2003, p.35). The related behaviours include purging and efforts to restrict the amount of food taken. It is not known exactly what causes the disorder, and a number of scholars assume that it is important to take a holistic approach and consider multiple factors. One community-based study (Zeeck & van der Kooij, 2009) compared 102 individuals with bulimia nervosa to 204 healthy controls and found that the patients with this disorder also had higher rates of mood disorder, “sexual and physical abuse, obesity, substance misuse, low self-esteem, perfectionism, disturbed family dynamics, parental weight/shape concern, and early menarche. Compared with a control group of 102 women with other psychiatric disorders, women with bulimia nervosa had higher rates of parental problems and obesity” (Zeeck & van der Kooij, 2009, p. 24). People with bulimia nervosa might also have psychological and emotional characteristics that influence the development of the disease: apart from low self-esteem and perfectionism, it is important to note the low ability to control impulsive behaviors and express emotions in a constructive, non-harming way (Hay & Bacaltchuk, 2003). It is also suggested empirically that biological factors might contribute to the probability of developing the disorder: for instance, young women with mother of biological sister, who have a history of an eating disorder, are considered to be at higher risk (Hay & Bacaltchuk, 2003). Studies of twins also corroborate this finding. In fact, serotonin, a natural brain chemical, is associated with food intake, so the imbalance in serotonin secretion might also cause binge eating. It also needs to be noted that girls and young women with anorexia nervosa are more likely to develop bulimia in the future (Hay & Bacaltchuk, 2003).
A number of scholars (Hay & Bacaltchuk, 2003; Lam & Lee, 2004; Wander Val, 2004) contend that Bulimia nervosa is difficult to identify due to the secrecy of purging and binge eating behaviours. Bulimia nervosa is not associated with weight loss (like in case of anorexia nervosa) and not always with weight gaining, which creates additional difficulties with diagnosis. The formal DSM-IV criteria for bulimia nervosa include binge eating, purging two times a week or more frequently in a three consecutive months, fear of weight gain, absence of anorexia. Lam and Lee, who dedicated their research to diagnosing issues, state that all patients in their case studies demonstrated several core features of bulimia nervosa: “overconcern with shape and weight, irresistible urge to overeat, recurrent bulimic episodes during which a large amount of food is consumed in a short period of time, and subsequent self-induced vomiting or other purging behaviours. A varying proportion of bulimic patients have a previous history of transient anorexia nervosa, their bulimia may represent “ a starved body rebelling to be fed” (Lam & Lee, 2004, p.229).
Treatment of the disorder
The first and most common type of intervention is psychotherapy, namely cognitive behavioural therapy. It normally lasts from 14 to 20 weeks and consists of three stages (Hay & Bacaltchuk, 2003). Firstly, the cognitive view on managing bulimia is presented and supported by useful behavioural techniques which allow establishing healthier eating patterns. “In the second stage, additional attempts are made to establish healthy eating habits, and an emphasis is placed upon the elimination of dieting. Cognitive processes (previously outlined) are focused upon extensively in this stage; the therapist and the individual examine his/her thoughts, beliefs, and values which maintain the eating problem” (Hay & Bacaltchuk, 2003). At the last stage, both therapist and patient work on maintaining the positive result gained during the treatment course. As compared to the pharmacotherapy, cognitive behavioural treatment normally has low dropout and withdrawal rate (40% vs. 18-20% respectively) (Hay & Bacaltchuk, 2003; Lam & Lee, 2004). In addition, cognitive behavioural therapy provides positive long-term gains in terms of abstinence from binge eating and purging; as compared to waiting-list controls, from 32% to 93% (mean 55%) bulimic patients, who took a psychotherapy course (as the results of three systematic reviews suggest), demonstrated a tendency to eliminating binge eating and purging behaviours, which was maintained for up to five years.
Another approach to combating bulimia is pharmacological therapy. The main substance used in such treatment courses is fluoxetine (Evans, 2004). The research by Evans suggests that 150 of 232 patients with bulimia nervosa positively responded to 8-week fluoxetine therapy, associated with taking antidepressants: the frequency of binge eating and vomiting episodes reduces over time (from 4.1 at the beginning to 2.9. at the final check), whereas in the placebo group the average number of episodes increased. However, due to the high probability of relapse, Evans notes that it is importance to continue fluoxetine maintenance for at least a year. Sibutramine (drug names – Meridia, Lindaxa) is a “neurotransmitter reuptake inhibitor that increases satiety. In more common terms, sibutramine makes the patient feel full by altering the balance of chemicals in the brain” (Evans, 2004, p. 57). It showed its effectiveness in reducing the adverse symptoms of binge eating disorder, but is currently not allowed in cases of bulimia nervosa, as bulimic patients are at higher risk of becoming underweight (they take in smaller amounts of nutrients due to the tendency to purging).
One more way of meeting the challenge of bulimia nervosa is gastric binding, which consists in surgical intervention into the structure and functioning of the patient’s digestive tract and combats rather the negative outcomes of bulimia nervosa, rather than its cause. This method is applicable only in those cases, when patients are obese or overweight ( Vander Wal, 2004).
Social and ethical considerations in diagnosis and treatment
As it has been noted before, bulimic patients often originate from dysfunctional families with the histories of alcohol and drug abuse, domestic violence and child maltreatment. In addition, a number of bulimic patients have society-related fears and phobias which might intensify binge eating and purging patterns (Vander Wal, 2004). This points to the necessity of viewing imbalanced families as an additional risk factor for relapse and failure to respond to therapeutic intervention. The biopsychosocial model currently employed in mental health dictates the need for altering patient’s family and social situation if it is not likely to contribute positively to the maintenance of therapeutic outcomes (Vander Wal, 2004). In particular, one of the directions of cognitive behavioral therapy for patients from families in social trouble might be learning social skills (communication, conflict management) and constructive self-evaluation and personality growth strategy. One of the priorities of CBT for bulimic patients with childhood traumas might be cognitive restructuring of negative experiences and formation of a healthy attitude towards the reference groups they belong to and people in general (Vander Wal, 2004). Family therapy for all members of the patient’s household might be administered as well in order to improve the family’s social adaptation.
When considering ethical issues, associated with the diagnosis and treatment of bulimia nervosa, it is important to keep in mind the fact that the disorder is characterized by secrecy, so patients normally try to avoid spreading information about their health problems. Therefore, it is important for the therapist or case manager to keep the information gained in clinical settings maximally confidential. Patients should also be informed about the possible outcomes and side effects of therapeutic interventions. Cognitive behavioural therapy might imply the patient’s exposure to their fears or irritants which contribute to the development of bulimia nervosa, and it needs to be noted that this process should be gradual and physically/psychologically safe.
To sum up, bulimia nervosa is an eating disorder which prevails in young women and is characterized with such behavioural patterns as binge eating and purging. It can be diagnosed and assessed appropriately only if the clinician considers all the factors which influence the development of the disorder and its social side, apart from the physical and psychological. Bulimia nervosa is treated using two main methods, pharmacological therapy (antidepressants) and psychotherapy (cognitive behavioral sessions). Both interventions show positive results, which consist in the reduction of the frequency of binge eating and purging episodes, improvement of self-image and self-esteem, but cognitive behavioral therapy is to some extent more effective and causes fewer side effects and lower withdrawal rates.
Hay, P. & Bacaltchuk, J. (2003). Bulimia nervosa. British Medical Journal, 7: 35-43.
Vander Wal, J. (2004). Bulimia nervosa and laparoscopic adjustable gastric binding. NAASO’s Newsletter, 1(5): 10-17.
Lam, J. & Lee, S. (2004). Three different presentations of bulimia nervosa. Hong Kong Medical Journal, 6: 227-230.
Evans, J. (2004). Fluoxetine in bulimia nervosa. Clinical Psychiatry News, 3: 57-72.
Zeeck, H. & van der Kooij, A. (2009). Severity of bulimia nervosa. Psychopathology, 42: 22-31.