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Bulemia: Evaluation and Treatment

Bulemia are the two psychiatric disorders that have the most significant degree of significant physical dysfunction because of the aberrant eating patterns and the problems that occur relative to nutrition. It is a disorder that occurs primarily in white, middle to upper class individuals. We are seeing anorexia gradually extend down into the lower socioeconomic classes. It primarily affects females between the ages of 12 and 20. The instance has increased from about 1:250 twenty years ago, to about 1:100 at the present time. There has indeed been a marked increase in the last 15 -18 years for this disorder. It is commonly seen in individuals who are involved in appearance-related sporting activities or in activities where appearance is a primary determinant of scoring; such as gymnastics, dance, modeling and acting. Thereís a significant female predisposition to this with a female to male ratio.

The mortality rate early on was 5% to 10%, and that was primarily because of starvation. The two most likely ways in which an anorexic individual will subsequently lose her life, are from suicide or from organ failure, particularly cardiac dysfunction and cardiac arrhythmias. While one would have expected the mortality rate hopefully to

Bulemia nervosa most commonly affects white middle and upper class individuals. Again, females aged 15 to 20. A little bit older. Anorexia we start seeing at 11, 10, 12 years of age. Bulimia oftentimes not until they are 14 or 15 years of age. Incidence is much higher than anorexia nervosa, 2% to 5% in the general population. Much greater than the 1% for anorexia nervosa. And up to 20% in some college surveys. In some surveys of college individuals, up to suicide and cardiac arrhythmias.

These individuals begin dieting, but they canít control the diet to the extent that the anorexic individual ultimately is able to. They get frustrated with the diet. Continue to want to lose weight and try to devise some shortcut by which they can get the weight loss to begin. So they being experimenting with purging behaviors. At first that really is an experimentation. At first, if they overeat just a little bit, "I think Iíll just throw up. Iíll get rid of it by

They then develop progressive escalation of purging behaviors. They are extremely secretive about their behaviors. Even more so than the anorexic. I have had some individuals who have been able, for over 15 years, to hide this from their husband, to hide it from other family members, to hide their bulimic purging behaviors from other individuals. We had a secretary once who worked with about 15 other secretaries, she know to the

Again, there are a number of factors which are more commonly present in families of individuals with bulimia nervosa. These are families that are disengaged. They have high conflict difficulties, low expressivity and high achievement goals. There are biogenetic factors which appear to be more

There are endocrine abnormalities that occur more commonly in these individuals than in the general population, so there is some supposition that these patients also have subtle endocrinologic abnormalities. They have a failure to suppress to the extent that you would expect on dexamethasone

The characteristic personality style for individuals who are at risk for developing bulimia nervosa includes affective instability and they have low self esteem. Affective instability means that they are impulsive, they have low frustration tolerance, low moods, highly variable moods and high anxiety levels. If you have an individual with that characteristic makeup as they go through adolescence, and are depicted with extreme low self esteem, they

What are the diagnostic criteria for bulemia nervosa? They are listed on this slide. There are five of those. Again, this is important to have general knowledge of. First of all, they have a problem with eating. They eat in a discreet period of time an amount of food that is definitely larger than most people would eat in a similar time and under similar circumstances. So they have a period of engorgement and during this process they can eat for

Frequency. They need those behaviors occurring both on the average at least twice a week for three months. Self-evaluation, again, in these individuals is unduly influenced by body shape and weight. If they havenít lost weight and if they havenít consistently controlled what theyíve taken in

The vicious cycle that we talked about is emphasized for us on this slide. They begin by dieting. Thatís unsuccessful. They canít deny the hunger signals. They develop a binge eating episode. They are anxious about their weight, they are anxious about the fact that they just ingested calories, they purge, they feel tremendous relief but almost at the same time a lot of guilt about the aberrance of these particular behaviors. They begin to try

What are the important aspects of their history that you need to focus on? Again, ask them about diet. Ask them about weight. Theyíll have a strong preoccupation with weight, diet and calories similar to the anorexic individual. Ask them about diet pill use. Are they using diet pills? Are they using laxatives? Are they using diuretics? These individuals will oftentimes have frequent sore throats because the back of their throat is always sore from

Treatment for these individuals: very similar to that for anorexics. You want to stop of course. You want to put them in an environment in which they can stop the purging behaviors. If they are just getting involved in it, oftentimes you can do this with outpatient counseling. But if not, you may need a short one-week period of hospitalization to stop the purging behaviors, correct any electrolyte abnormalities and again, begin them with psychotherapy and nutritional counseling. Again, utilizing the cognitive behavioral approach is found to be the most effective for patients with either type of eating disorder. If the individual is purging by using laxatives they will maintain themselves in a state of dehydration even more significantly.

Management, again, exercise, physical and occupational therapy is important. Bowel regulation. These individuals have some problems with constipation. We donít like to use stimulant laxatives. We will use primarily psyllium or milk of magnesia, and occasional enemas. Try to get them off the laxatives that theyíve oftentimes been using prior to their coming in. Again, weight management.

We use a calorie point systems. One point equals 75 calories. Itís a lot easier to count up to 20 to 25 points a day, or 30 points a day, than it is to count 6,000, 4,000, 2,000, calories in all of the foods that they have. Cognitive behavioral therapy is again the therapy that works.