Bulimia Nervosa and Binge Eating Disorder

Johanna Bickel/ CC BY-SA 4.0

(by Johanna Bickel)

Datum: 21. 2. 2017
Host: Mini-Med Studium
Location: Van-Swieten-Saal der Medizinischen Universität Wien
Event-type: Vortrag
Participants: Ao. Univ.-Prof. Dr. Ursula Bailer, FAED, Univ.-Klinik für Psychiatrie und Psychotherapie, Leitung der Ambulanz für Essstörungen, AKH Wien

On the evening of February 22nd 2017, Prof. Ursula Bailer held the second part of the event with the title „Too little and too much — do we have a disturbed relationship to food?“ in the Van-Swieten Saal of the Medical University of Vienna. As head of the out-patient clinic for eating disorders of the Vienna General Hospital (since 2001), she focuses on eating disorders where “too much” food is consumed, in particular, therefore, bulimia nervosa and the binge eating disorder.

She started her lecture by pointing out that also these disorders, in most cases, begin with a diet or over-rigid eating behaviour, although with both disorders an excessive food intake is in the foreground.

In this context she refers to the possibly personal experience that, when a diet is started, thoughts start to circle around food very strongly or that an excessive preoccupation with food arises.

That which actually should be avoided thereby becomes the central content of an individual’s thoughts.

Subsequently this, not only psychopathological but also clinical pathology leads to a loss of control in everyday life; binge eating can become a consequence, i.e. in a very short period of time a huge amount of food is consumed.

Being on a diet per se can also lead to a very selective food intake, such as the special cutting of food as well as a specific unusual combination of food (for example, sweet and sour). Further consequences of being on a diet are depressiveness, irritability and, after a longer period, social withdrawal, isolation and impairment of school or employment performance.

As such, being on a diat does not only affect one person — it is possible that there are also changes in the family structure, potential secondary gains for the patients and also those changes, already mentioned in the first part, in the neuronal regulatory structures due to nutritional limitations.

Bulimia nervosa

The characteristics of this disorder are, in particular, uncontrolled episodes of binge eating. Within these episodes, large amounts of food are consumed in a short period of time, which is accompanied by a feeling of loss of control. Despite these attacks, in the times between them, there is an excessive preoccupation with food intake, greed or a pressure to eat.

Similar to the “purging type” sub-type with patients suffering from anorexia, where binge eating also occurs, patients suffering from bulimia try to counteract weight gain through such attacks.

In the case of a single attack, up to 8,000 calories are commonly ingested. The most common compensation mechanisms include self-induced vomiting, very restrictive eating behaviour between the binge eating (which consequently would provoke these), abuse of laxatives, diuretics, thyroid medication or appetite suppressants.

The excessive, compulsive practising of sports, with the intention of burning the consumed calories, is also very common (see the criteria of bulimia nervosa according to the American Diagnosis Manual). A further feature are patients who not only suffer from diabetes mellitus, but also from an eating disorder, who often lose weight as a result of the practice of so-called “insulin purging” (intentional insulin omission). An appropriate attitude or treatment of diabetes is hardly possible with these patients.

Analogue to anorexic patients, bulimics also have a phobia of weight, i.e. they are extremely scared of becoming fat or gaining weight, although they are of normal weight. There is often a pendulum between anorexia and bulimia, the transitions are fluid.

The criteria of bulimia nervosa, according to the American Diagnosis Manual (DSM-IV)

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
  2. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting, or excessive exercise.
  3. The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for three months.
  4. Self-evaluation is unduly influenced by body shape and weight.
  5. The disturbance does not occur exclusively during episodes of anorexia nervosa (in this case it concerns the anorexia nervosa: bulimic type)
Also within bulimia nervosa, a differentiation is made between a “purging type” and a “non-purging type”. The purging type compensates a potential weight gain with vomiting or with the use of laxatives, the non-purging type with extreme sport or hunger periods between the eating attacks.

Indirect indications

Whilst anorexia nervosa can be diagnosed visually, bulimia is often not recognised. Prof. Bailer states that she herself is always astonished how often and how long patients suffering from bulima can hide it from their families. The patients often need a long time to overcome their feeling of shame and to seek help.

There are more often indirect indications for bulimia. These include hypertrophy (swelling) of the salivary glands (parotide gland), which can lead to a mumps-like appearance. Dentists commonly raise suspicions as they find tooth damage (enamel defects, the development of caries, a loosening of fillings) due to the sour contents of the stomach. Often anguar cheilitis (tears in the corner of the mouth) and a callus formation on the index finger (due to contact of the incisors with the finger when triggering the gag reflex, also called “Russel sign”) are evident. Depending on the experience with vomiting, petechiae (author’s comment: punctiform haemorrhages) can appear on different parts of the body.

Binge eating disorder (disorders with eating attacks)

The binge eating disorder is also characteristised by extreme eating attacks, which are accompanied by great psychological stress on the part of patients. Similar to bulimia nervosa, these attacks often occur secretly and alone. Those affected very often feel shame due to this behaviour.

The amount of calories ingested in an attack is often even greater than that in the case of bulimia.

After an eating attack, patients are disgusted with themselves, depressed and feel very guilty. Patients suffer massively from the binge eating disorder.

Definition of the binge eating disorder according to the American Diagnosis Manual (DSM-IV)

  • Recurrent episodes of binge eating. An episode is characterized by:
  1. Eating a larger amount of food than normal during a short period of time (within any two-hour period).
  2. Lack of control over eating during the binge episode (i.e. the feeling that one cannot stop eating).
  • Binge eating episodes are associated with three or more of the following:
  1. Eating much more rapidly than normal.
  2. Eating until feeling uncomfortably full.
  3. Eating large amounts of food when not physically hungry.
  4. Eating alone because you are embarrassed by how much you’re eating.
  5. Feeling disgusted, depressed, or guilty after overeating.
  • Marked distress regarding binge eating is present.
  • Binge eating occurs, on average, at least two days a week for six months.
  • Binge eating is not associated with the regular use of inappropriate compensatory behaviour, i.e. fasting
  • Substance abuse (laxatives or diuretics).
  • Excessive exercise.
  • Binge eating does not occur exclusively during the course of:
  1. Anorexia nervosa
  2. Bulimia nervosa
The great difference to bulimia is that patients do not take compensatory actions after an eating attack. Due to the huge amounts of unburned calories, the binge eating disorder leads to obesity over a longer period of time.

Frequency of bulimia and the binge eating disorder

In the high-risk group of 15- to 35-year-olds (peak age around the age of 18), bulimia occurs somewhat more frequently than anorexia.

The point prevelance (frequency at a certain time) lies at approx. 1%, while 90–95% of patients are female. Subsyndromal characteristics (in this case all symptoms of the disorder are not present) occur more frequently; Prof. Bailer speaks of a prevalence of up to 20%. Dieting as a risk factor for the development of an eating disorder is particularly widespread among female secondary school pupils and often occurs as a group activity.

The binge eating disorder has an even higher point prevelance among the population at 2–5%. A significantly greater number of men are affected — almost one-third of patients. However, only a small part of the overweight population suffer from the binge eating disorder.

Within the scope of weight loss programmes, there is, however, often a number of people with a binge eating disorder. According to Prof. Bailer, it is important here to regognise and diagnose the illness. Also among patients who undergo bariatric surgery (overweight surgery) is the binge eating disorder widespread.

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