pt 2 Exhaustive Guide to Bulimia Nervosa, Body Image Disturbances, and Treatment Approaches

Bulimia is fundamentally characterized by two distinct behaviors: episodes of binge eating and the use of inappropriate compensatory methods to prevent weight gain.
Compensatory behaviors represent efforts to counteract the caloric intake of a binge and include processes such as self-induced vomiting, purging, the use of diuretics, the use of laxatives, the use of enemas, excessive exercise, and fasting.
Clinically, bulimia is distinguished from anorexia by weight; in anorexia, weight is typically $15\%$ below the expected weight, whereas individuals with bulimia are usually within $10\%$ of their target weight.

A binge is defined as eating an amount of food that is definitely larger than what most people would eat during a discrete period (typically any two-hour period) under similar circumstances.
A critical component of a binge is the psychological sense of a lack of control; the individual feels they cannot stop eating or control the quantity being consumed during the episode.
Contextual Distinction: Eating a large holiday meal (like Thanksgiving) is common and normal under those circumstances. A binge involves eating excessive amounts, such as an entire box of Oreos or a half-gallon of ice cream, in situations where others would not.
Caloric Data: * The clinical definition of a binge is often set at an intake of $1,200$ calories consumed at once (note: some fast food hamburgers can reach this threshold quickly). * The average binge typically ranges between $4,000$ and $5,000$ calories. * Subjective Binging: Some individuals may define a binge based on very small caloric intake, such as a single candy bar, if it triggers a sense of being overwhelmed and is followed by compensatory behavior.

Frequency and Duration: To meet the diagnostic criteria for bulimia, the binge-purge cycle must occur on average at least twice a week for a duration of three months.
Self-Evaluation: The individual's self-worth and self-evaluation are unduly influenced by their body shape and weight.
Subtypes of Bulimia: * Purging Subtype: This is the most common form, accounting for over $90\%$ of cases. It involves vomiting or the misuse of laxatives, diuretics, or enemas. * Non-Purging Subtype: This involves compensatory behaviors such as excessive exercise or fasting following a binge. This subtype is much less common, possibly because such behaviors often lead to the weight levels associated with an anorexia diagnosis.

The Cycle: Often triggered by stress—such as a difficult social interaction or a stressful historic event—the person binges. While the binge may provide temporary relief, it is followed by feelings of being out of control, shame, embarrassment, and physical discomfort or distension.
Secrecy: Individuals are often very secretive about both their binging and their purging behaviors.
Mental Health Comorbidity: Bulimia is frequently associated with mood problems (depression), anxiety struggles, and substance abuse problems. Many individuals become increasingly socially withdrawn.
Physical Sensation: Purging and ingesting massive amounts of food can be physically painful; the person often feels uncomfortable and physically distended.

Purging methods (vomiting, laxatives, enemas) can lead to severe medical outcomes and are potentially fatal.
Electrolyte Imbalance: Disruption of the electrolyte system—specifically levels of potassium, calcium, and sodium—which are vital for neurological and cardiovascular functioning.
Digestive System Damage: Risks include stomach damage, esophageal tears, diverticulitis, ulcers, and other gastrointestinal problems.
Mortality: Bulimia has a death rate of $10\%$ . One in ten individuals will die prematurely due to complications such as cardiac arrest, suicide, or the disorder merging into anorexia.

Prevalence: Lifetime prevalence is between $1\%$ and $3\%$ . The vast majority of those affected are female.
College Populations: Between $6\%$ and $10\%$ of college women struggle with bulimia, which is higher than the general population rate.
Onset and Course: Typically begins in late adolescence to early adulthood. If left untreated, the disorder tends to be chronic, often characterized by a pattern of remission followed by recurrence.
Medical Treatment: Antidepressants have been tried to reduce binging, but they are not considered efficacious in the long term.
Psychological Treatment (Treatments of Choice): * Cognitive Behavioral Therapy (CBT): The primary treatment of choice; six-year follow-up data shows consistent rates of remission and stable long-term gains. * Interpersonal and Family-Focused Intervention: Also shows great long-term gains, sometimes with higher long-term follow-up success than immediate post-treatment gains. * Behavioral Therapy (e.g., Behavioral Activation): Creates some post-treatment gains, but these are generally not as stable or effective long-term compared to CBT.

High Risk Behaviors: Roughly $60\%$ of college women engage in some form of eating disturbance, such as chronic dieting or restrained eating, that does not necessarily meet a full clinical diagnosis.
College Athletes: This population shows high rates of high-risk behaviors. Female athletes often engage in vomiting, laxative use, and diet pill use. Male athletes (and some females) are more likely to use "sweat weight loss" methods like saunas and steam rooms, which are significantly dangerous.

Personality Profile: Individuals susceptible to these behaviors were often high-achieving, perfectionistic, and overly compliant as children.
Family Environment: There is often a heavy family emphasis on physical beauty.
Early Dieting: One study indicated that $70\%$ of women were placed on diets as early as elementary school by parents, often due to parental perception of body type rather than medical obesity.
Puberty: Natural developmental changes in female bodies during puberty (evolutionary adaptations for childbirth) can lead to body dissatisfaction if evaluated as unacceptable by the individual or their family.

Direct Communication: Be direct and tell the person you are concerned for their health. Use specific observations (e.g., "I've noticed you don't come to dinner with us anymore; that was a great time for us to catch up").
Avoid Comments on Thinness: Do not repeatedly comment on a person's thinness or weight loss. These comments can be viewed as compliments or sources of jealousy, which may reinforce the disordered behavior.
Anticipate Reactions: The person may feel a tremendous sense of relief in sharing their secret, or they may respond with strong anger and defensiveness.
Provide Support: Emphasize caring, remain compassionate, and offer encouragement that recovery is possible. Even in cases of anorexia, people do get better through support and treatment.