Bulimia nervosa is an eating disorder described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with five key features. These features are; cyclical episodes of binge eating, chronic compensatory habits such as purging, diuretic use, laxative use, fasting and excessive exercise to avoid weight gain, obsessive concern over body weight and shape. All these are aimed at expelling the calories consumed during the binge eating period (Jimerson et al., 1988). The disorder is established if this feeding behavior happens at least once every week in three months. Its etiology is linked with genetic factors such as abnormal levels of serotonin. Also, environmental factors have a role in this through media presentation of the ideal body. Bulimia nervosa is more common among women, and onset is usually in the late teen years.
Anorexia nervosa is a life-threatening disorder associated with low weight, dietary restriction, an absolute fear of gaining weight, and a constant desire to be thin. Individuals with anorexia often perceive themselves as being overweight, while in a real sense, they are skinny and refuse to acknowledge that they are underweight (Jimerson et al., 1988). The etiology of anorexia nervosa takes genetic, biological, psychological, and social angles. Genetically it is linked with variations in the serotonin genome; biologically, it is associated with the disruption of the serotonergic and dopaminergic pathways, while sociologically, it is connected with the desire to meet the western world standards of beauty. It affects more women than men and is more common among adolescents than other age groups.
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Difference between bulimia and anorexia nervosa
In both eating disorders, the individual is obsessive with losing weight and tries to achieve it in unhealthy ways, as mentioned above. The critical difference between the two is seen in their behavioral characteristics (Vitousek & Manke, 1994). People with bulimia have episodes of binge eating, which is featured with overeating, followed by purging. People with anorexia, however, overly restrict their diet to points of malnourishment. They also engage in excessive exercise to lose weight. Usually, at the time of diagnosis, people with anorexia are fragile due to self-starvation with a weight loss of up to 15%. Still, in bulimia, the person has normal weight in most cases.
Psychological disorders associated with bulimia and anorexia
Both disorders are regarded as psychological and psychiatric conditions, thus their classification in the DSM-5. They have a mental impact and often occur together with depression, anxiety, obsessive-compulsive disorder, drug, and substance abuse (Jimerson et al., 1988). It is mainly tied to upsetting thoughts and emotions in the individual. Other psychological risk factors are developmental problems such as low self-esteem, self-regulation, identity problems, and unsettled conflicts. Bulimia is highly associated with post-traumatic stress disorder (PTSD) and antisocial personality disorder.
Clinical description of Bulimia and Anorexia nervosa
Bulimia can go for many months and even years before it is diagnosed because most patients keep the condition a secret and are surrounded by feelings of shame and guilt. Their health-seeking behaviors are mostly related to other problems, bowel irregularities, bloating, and fatigue, but not for the eating disorder. They also seek help for their mental health, presenting with mood swings, family feuds, childhood trauma, and anxiety problems (Vitousek & Manke, 1994). The following symptoms mark the disorder's clinical course: palpitations, dizziness, abdominal cramps, hematemesis, constipation, flatulence, dysphagia amenorrhea, and pulmonary symptoms. Questionnaires, SCOFF, and ESP are used to confirm diagnosis alongside laboratory and imaging studies.
Clinical description of anorexia entails premorbid conditions such as anxiety and chronic affective disorders revealed through a psychological profile (Vitousek & Manke, 1994). It is essential to pay attention to patients' sense of self-worth and self-esteem and careful history taking with details on feeding habits, diet, weight changes, and determination of their body mass index. Common signs and symptoms observed are; headaches, irritability, alopecia, edema, pale, dry skin, hypercarotenemia, dizziness, constipation, distorted body due to malnourishment, and mental symptoms social withdrawal, depression, and poor concentration. Hypothermia, hypotension, low blood glucose, reduced blood count, muscle wasting, and elevated liver enzymes are present in severe cases due to low energy levels. Diagnosis is confirmed using the SCOOF questionnaire together with laboratory tests and imaging.
Common comorbidities between bulimia and anorexia
These eating disorders are psychological and occur concurrently with other psychiatric conditions. According to research, about 80% percent of patients diagnosed with bulimia or anorexia also present with psychiatric symptoms (Jimerson et al., 1988). The most common being depression, anxiety, mood disorder, sexual dysfunction, substance abuse, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Suicidal thoughts, ideations of self-harm, and death by suicide are also more common among affected individuals.
Complications of the disorder present with esophagitis, arrhythmias, chronic gastric reflux, perimolysis, peptic ulcer diseases, electrolyte imbalance, gastroparesis, infertility, and cardiac arrest. Hospitalization due to these conditions increase the risk of exposure to nosocomial infections. Susceptibility to disease and suicide increases the mortality rates for individuals with these disorders.
Treatment
Pharmacotherapy and psychotherapy are both effective in the treatment of both disorders. Nutrition-based interventions, supportive therapy, and self-help therapies are also efficacious in the mitigation of the condition. Treatment is done either in outpatient or inpatient settings, depending on the severity of the disorder. In instances of severe complications and metabolic abnormalities, the patient must be admitted. Therapy is also interdisciplinary, involving a dietitian, psychiatrist, physicians, and nurses. The treatment goal is usually to eliminate the disorder, manage complications, treat underlying psychiatric conditions, and educate and counsel.
Treatment of bulimia involves psychotherapy using (CBT) cognitive behavioral therapy, which helps the patient keep records of the food they eat and vomiting episodes. Family-based treatment (FBT) is also pertinent, especially in adolescents who need a support system to help them overcome the illness. Interpersonal psychotherapy, group therapy, and nutritional counseling are some of the adjunct therapies also employed in treatment. Pharmacotherapy with antidepressants, particularly Selective Serotonin Reuptake Inhibitors such as fluoxetine, is approved by the FDA (Kaye et al., 1998). Other antidepressants such as bupropion and tricyclic amines such as imipramine have also been shown to be effective. Mood stabilizers such as topiramate and lithium are also used; however, topiramate has been established to produce intolerable adverse effects. Therefore, it is only used when other medications have been proven to be ineffective. Alternative therapies such as hypnotherapy have also been proven to produce positive results.
Clinical steps used in the treatment of bulimia can be applied in the management of anorexia. Vitamin and calcium supplementation are additionally utilized in alleviating disease. In complications states involving a reduction in bone density, estrogen has been recommended; however, hormone therapy has not yet been established. Diet, refeeding strategies, and meal planning are also valuable in this group of patients to help them regain the weight (Kaye et al., 1998). Refeeding should be done slowly with respect to the patient’s metabolic demands with an assessment of the patient's levels of vitamins to prevent the emergence of refeeding syndrome associated with electrolyte balance resulting in cardiovascular collapse.
Patients with bulimia nervosa and anorexia nervosa require close monitoring and follow-up. This owes to the fact the condition is associated with feelings of low self-esteem, denial, guilt, and shame, which may limit their health-seeking behavior. Harm minimization should be used in chronic cases to prevent injury and even death due to their vulnerability to suicidal ideations and self-harm.
References
Jimerson, D. C., Brandt, H. A., & Brewerton, T. D. (1988). Evidence for altered serotonin function in bulimia and anorexia nervosa: Behavioral implications. The Psychobiology of Bulimia Nervosa , 83-89. https://doi.org/10.1007/978-3-642-73267-6_9
Kaye, W., Gendall, K., & Strober, M. (1998). Serotonin neuronal function and selective serotonin reuptake inhibitor treatment in anorexia and bulimia nervosa. Biological Psychiatry , 44 (9), 825-838. https://doi.org/10.1016/s0006-3223(98)00195-4
Vitousek, K., & Manke, F. (1994). Personality variables and disorders in anorexia nervosa and bulimia nervosa. Journal of Abnormal Psychology , 103 (1), 137-147. https://doi.org/10.1037/0021-843x.103.1.137
