Bulimia is an eating disorder that is driven by a lack of control over eating, manifest as recurrent episodes of bingeing, coupled with a paralyzing fear of becoming fat. It is associated with depression or other psychiatric disorders and has symptoms that overlap with another major eating disorder, anorexia nervosa. (Note: For information on anorexia nervosa, see the Integrative Medicine Access monograph, "Anorexia Nervosa.") Because self-evaluation is unduly influenced by body shape and weight in this disorder, compensatory behavior ensues. This may involve self-induced or medication-induced (e.g., syrup of ipecac) vomiting; misuse of laxatives, diuretics, or enemas; fasting; or excessive exercise. Criteria for bulimia require that it occurs at least twice a week for three months and that it does not occur exclusively during periods of anorexia nervosa. Bulimia has two subtypes: purging and nonpurging.

Bulimia primarily affects adolescent and young adult women. Prevalence among females overall in the United States is approximately 1% to 2%, with men being affected about a tenth that number. However, among female college students, specifically, the rate of vomiting after eating may be as high as 18%.

Familial and psychological factors in the etiology of bulimia include an increased prevalence of eating and mood disorders and substance abuse in families of bulimic patients, and of depression, self-mutilation, substance abuse, and obsessive-compulsive behavior in patients. The role of sexual abuse in bulimia remains controversial. Cultural pressures to appear slender are significant, and bulimia affects dancers and athletes more frequently.

Inducing tryptophan (the precursor to serotonin) depletion in subjects known to be at risk for bulimia results in a subjective loss of control of eating. Effects of acutely lowering serotonin transmission in these subjects also resulted in significant relapses in depressive symptoms. Serotonin-mediated neurotransmissions are thought to be a component of the body's ability to recognize satiety.

• White, middle-class females
• Genetic
• Lack of self-esteem; separation/individuation issues

• Binge eating of high-carbohydrate foods, typically at least once a day; up to 50,000 kcal/day consumed; 1 to 46 episodes per week; usually in secrecy
• Loss of control over eating, with guilt and shame
• Fluctuating weight
• Constipation, diarrhea
• Bloating, borborygmus, flatulence
• Abdominal pain, nausea
• Dehydration
• Blood-tinged vomitus
• Secondary amenorrhea; irregular menstruation
• Bradycardia, with malnutrition
• Eroded tooth enamel
• Halitosis
• Pharyngitis, esophagitis
• Calluses on dorsal surfaces of hands from manually induced vomiting
• Stealing, especially food
• Depression
• Substance abuse, especially alcohol

• Klein-Levin syndrome
• Kluver-Bucy syndrome
• Neurologic disease: CNS tumors, seizures
• Insulin-dependent diabetes
• Anorexia nervosa
• Inflammatory bowel disease
• Thyroid disease/hypothalamic tumor
• Peptic ulcer
• Cholelithiasis
• Hepatitis
• Other psychiatric disorders

The physical examination may be unrevealing in part because bulimic patients are often of normal weight. Teeth erosion is common. Parotid enlargement may be apparent. The patient may show clinical signs and symptoms of depression.

Repetitive bingeing and purging may result in various laboratory abnormalities.

• Complete blood count—investigating possible anemia
• Serum electrolyte—may be normal, even with repeated purging; but may show hypokalemia, hypochloremia, hyponatremia, hypomagnesemia; metabolic alkalosis may occur
• Elevated serum amylase levels
• Elevated serum BUN/creatinine levels
• Urinalysis
• Decreased serotonin
• Decreased cholecystokinin
• Low basal prolactin levels
• Dexamethasone suppression of plasma cortisol
• Measurement of zinc and other trace minerals

• Psychological—obsessive-compulsive behavior, antisocial behavior, self-mutilation
• Intestinal dilation and diminished motility
• Eroded tooth enamel
• Esophagitis, Mallory-Weiss tears from repetitive induced vomiting.
• Parotid gland enlargement

CT scan may reveal brain atrophy with dilated ventricles.

• Body mass index (weight in kg/height² in meters) of less than 18 is diagnostic of anorexia, warrants change in diagnosis
• Endoscopy may reveal esophageal inflammation or erosion and colonic dilation.
• Goldberg Anorectic Attitude Scale, Eating Attitudes Test to assess body self-image
• Gastric motility test
• Thyroid, liver, and renal function tests
• Electrocardiogram to detect bradycardia, signs of hypokalemia, or ipecac-induced myopathy; also, helps determine safety of psychopharmacology.

A multidisciplinary approach is recommended. Interpersonal therapy or cognitive-behavioral therapy helps patients cope with dysfunctional urges. These therapies decrease incidences of bingeing and purging up to 80%. Family therapy is useful for adolescents. Psychopharmacology is reported to enhance the benefits of cognitive-behavioral therapy. Comorbid psychiatric disorders must be treated. Patients should be educated about the dangers of bingeing and purging. Hospitalization is not required except with medical emergency and suicidal ideation.

• Selective serotonin reuptake inhibitors (SSRIs): fluoxetine, 60 mg/day (higher than the standard dose generally given for depression); trials of 8 to 16 weeks show efficacy for moderate to severe bulimia; currently the only FDA-approved drug for bulimia; sertraline, 50 to 200 mg/day; paroxetine, 20 to 60 mg/day; fluvoxamine, 50 to 200 mg/day.
• Tricyclic antidepressants: imipramine, 10 mg, gradual increase to 250 mg if needed (maximum 100 mg for adolescents); desipramine, 25 mg/day, increase gradually to 150 mg/day. Monitor with ECG.
• Monoamine oxidase (MAO) inhibitors: phenelzine, 60 to 90 mg/day. Patients with atypical depression may respond to MAO inhibitors. To avoid food-related hypertensive crises, use MAO inhibitors only with cooperative patients.
• Potassium supplementation

If patient does not respond, try drug in a different class. Antidepressant medication should be maintained at full dose for at least one year to prevent relapse. If changing from SSRI to MAO inhibitor or vice versa, allow five weeks in between to avoid serotonin syndrome.

As discussed in the section entitled Treatment Strategy, cognitive behavioral psychotherapy is one of the cornerstones of bulimia treatment. In addition to its role in assessing stress level, biofeedback appears to be an effective adjunct therapy in the treatment of anorexia, frequently associated with bulimia, mediating emotional stress and coping mechanisms (Pop-Jordanova 2000). Other mind-body and stress reduction practices, such as yoga, tai chi, and meditation, may prove to help re-establish functional body image and awareness as well. Nutritional management is equally important to psychotherapeutic interventions; some research, as discussed in the section entitled Nutrition, suggests that this aspect of treatment may be a more important treatment.

A controlled clinical trial to study bulimia and guided imagery is significant, in part, because it is the first clinical trial to target problems with regulating emotion or ability to self-soothe, issues that characterize bulimia. Researchers found that guided imagery reduced the number of binge eating and vomiting episodes, improved self-comforting and measures of aloneness, and appeared to improve attitudes about body image, eating and dieting. The study was a six-week intervention; therefore, long-term benefit could not be established. Esplen and co-investigators suggest that the guided imagery approach may be useful as an adjunct to other treatments for bulimia but further research is needed to replicate the results, determine if there are long-term benefits, and explore the specific mechanisms of the model (Esplen et al. 1998).

In patients with eating disorders, serum levels of trace metals, such as zinc, are often depressed. In addition, gastrointestinal complications, such as delayed gastric emptying, bloating, and postprandial fullness, are common (McClain et al. 1993). Treatment goals are to stabilize blood glucose levels, to maintain electrolyte balance and nutrient stores, and to restore optimal gastrointestinal function. Cravings, usually for sweets or carbohydrates, may reflect inadequate nutrient intake. Patients may not recognize appetite signals and should be advised to eat small meals every three hours (Mooney 1997).

In a randomized comparison of nutritional management (NM) to stress management (SM) for the treatment of bulimia, the group receiving NM showed a more rapid reduction in the frequency of bulimic episodes and a higher abstinence rate from binge eating. Fifty-five female patients were randomly assigned to one of two treatment groups. In the NM group, participants were given detailed information about nutritional, biological, physiological and psychological effects of bulimia, along with an analysis of nutritional diaries, techniques to avoid binge eating, and encouragement and advice regarding adequate eating patterns, meal preparation, and introducing feared (binge) foods into the diet. Participants in the NM group were encouraged to eat three meals and one or two snacks each day, regardless of feelings of hunger or appetite. Although there were a few shared features of the two treatments (e.g., self-monitoring of eating behavior), the unique features of the SM group were: analysis of stressful situations; development of short-term strategies; and training in progressive muscle relaxation, problem-solving, and communication skills. Better outcomes were observed in the NM group throughout treatment and follow-up. At the 12-month follow-up, abstinence rates were 56% for the NM group and 25% for the SM group (Laessle et al. 1991).

Zinc deficiency has been observed in patients with eating disorders. Because zinc is associated with stress, taste, smell, and appetite regulation, deficient levels may perpetuate disordered eating habits and may contribute to altered self-image. Zinc supplementation appears to be beneficial in resolving dysfunctional body image and regulating appropriate appetite signals; some investigators report early remission of eating disorders using zinc supplementation combined with psychotherapy. In a recent study of 47 female bulimic patients, supplementation consisted of 120 mL of zinc sulfate administered for an average of 8.3 days; results (which have been submitted for publication) suggest that zinc reduced obsession with weight and concern over body image as measured by "fat anxiety" and "weight vigilance" on the Multidimensional Body-Self Relations questionnaire and "drive for thinness" and "body dissatisfaction" as measured on the Eating Disorder Inventory (EDI) (Schauss and Costin 1997). A multivitamin with minerals may be warranted for patients with bulimia since adequate nutritional intake is not assured. B-complex vitamins may help alleviate stress and reduce symptoms of depression.

Although no scientific literature supports the use of herbal remedies specifically for bulimia, guidance from a trained specialist may allow for supportive treatment of this eating disorder.

Although no scientific literature supports the use of homeopathy specifically for bulimia, a trained specialist would determine value and appropriateness of this approach on a case by case basis. Homeopathic treatment can address both constitutional and acute aspects of disease in general. In homeopathic terminology, the constitutional state reflects a pattern of underlying vulnerability or weakness that is unique to the individual and persists throughout that person's life. Symptoms tend to alternate over time, and treatment consists of selecting the appropriate remedy specific for the patient's constitutional type. By contrast, in acute conditions a remedy can be administered without reference to any particular constitutional state (Ullman 1995).

Although no scientific literature supports the use of acupuncture specifically for bulimia, guidance from a trained specialist may allow for supportive treatment of this eating disorder.

Therapeutic massage is an effective adjunct therapy for bulimia. A randomized, controlled study of 24 female bulimic inpatients receiving massage therapy for five weeks showed immediate improvements in the massage therapy group. Patients remained fully clothed while receiving a therapeutic massage. Massage techniques included smooth strokes, gentle rocking, stretching, traction, and friction. Pre- and post-therapy sessions were assessed by the State Trait Anxiety Inventory, Profile of Mood States Depression Scale, Behavior Observation Scale, and salivary cortisol. Long-term effects measured at first and last day of treatment were evaluated by the EDI and the Center for Epidemiological Studies Depression (CES-D) Scale. In addition, urine samples were evaluated for cortisol, serotonin, creatinine, and catecholamines. Patients in the massage group who were tested immediately after the treatment revealed significantly lower scores on anxiety and depression. Stress scores were markedly lower on the first day for the massage group but not on the last day. Evaluation of long-term effects in the massage group showed improved scores on the EDI subscales, reduced depression, higher dopamine, and decreased cortisol levels. There were no significant changes in the control group (Field et al. 1998).

Patient's weight, exercise habits, suicidal ideation, and medical status need to be periodically monitored, as bulimia is a long-term disease for most patients.

Severely symptomatic or suicidal patients are treated at specialized inpatient hospitals to prevent further complications.

Medical complications arise from metabolic dysfunction resulting from bingeing and purging.

• Esophageal or gastric rupture
• Pulmonary aspiration with asphyxiation
• Cardiac arrhythmias
• Pancreatitis
• Ipecac-induced myopathy
• Cardiomyopathy

Relapse occurs in about two-thirds of patients within a year of recovery. Follow-up data indicate about 50% full remission at 3 to 10 years. Approximately one-quarter improve and the other quarter remain unchanged.

Amenorrhea prevents pregnancy, and poor nutritional status may affect the fetus. Symptoms can increase or decrease during pregnancy. Pregnancy may be a particular challenge for women with eating disorders; follow-up is necessary to prevent relapse.

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