This web site was partially supported by the
Health Resources and Services Administration, Maternal and Child Health Bureau
through grant number 6T76-MC00011
Disorders during Adolescence: Nutritional Problems and Interventions
Jane Mitchell Rees, PhD, RD, CD
Departments of Health Services and Pediatrics
Maternal Child Health and Adolescent Medicine
University of Washington, Seattle, WA 98195
Chapter 7 Bulimia Nervosa in
[Table of Contents]
Bulimia Nervosa: Overview
First called bulimarexia, bulimia nervosa is a more recently recognized
eating disorder than anorexia nervosa. Bulimia nervosa is characterized
by gorging on food followed by one of several extreme behaviors in attempts
to rid the body of food and weight. These symptoms may also be associated
with starvation in anorexia nervosa but do not occur exclusively in that
disorder. [See APA
Bulimia Nervosa: Behavior and onset in adolescence
The adolescent suffering from bulimia nervosa often maintains close-to-normal
weight-for-height-for-age, meanwhile eating abnormally large amounts of
food, (known as binge eating) and regularly forcing her bowels to empty
by taking laxatives (called purging) or voluntarily vomiting. They
may also resort to fasting or extreme forms of exercise rather than vomiting
and/or purging. These behaviors, designed to rid the body of food,
weight and bulk, may be referred to collectively as purging. Professionals
must inquire carefully to determine what practices are described as "purging"
in a specific situation. Adolescents with bulimia nervosa may have
somewhat less severely distorted perceptions of their body shape and size
and less restrictive weight goals compared with those suffering from anorexia
nervosa. Adolescents with bulimia nervosa are often older at age of onset.
Bulimia Nervosa: Diagnostic criteria
Psychiatric Association (APA) criteria may be found at their web site.
The diagnostic criteria established by the APA includes the following behaviors:
Further two specific TYPES are described:
Recurrent episodes of binge eating, rapid consumption of abnormally large
amounts of food in a discrete period
Sense of inability to control binges and eating
Regular self-induced vomiting, misuse of laxatives, diuretics, enemas or
other medications, fasting, or excessive exercise (inappropriate compensatory
Occurrence of binge-eating episodes and compensatory behaviors on average
at least twice a week for 3 months
Self evaluation inappropriately based on body shape and weight
PURGING has regularly and is currently engaged in:
self induced vomiting, or misuse of laxatives, diuretics or
NON-PURGING has regularly and is currently engaged in:
fasting or excessive exercise and nor other compensatory behaviors
Note that specific compensatory behaviors are listed in the criteria.
While some are categorized under PURGING TYPE and others NON-PURGING TYPE,
each has specific detrimental effects and all should not be referred
to non-descriptively together as purging (as many adolescents will do)
but specifically identified and treated.
Bulimia Nervosa: Prevalence
The syndrome of bulimia nervosa should be differentiated from the recent
behavior of many normal adolescent females who try to control their weight
and shape by occasionally causing themselves to vomit. These young
women may also use laxatives or diuretics to rid themselves of body fluids
and the products of digestion. By college age as many as 20% of females
may engage in these inappropriate behaviors. Only about 2-4% of college
age women have serious disorders that meet the diagnostic criteria for
bulimia nervosa. The effected population is more diverse than with
anorexia nervosa; more are women of color, older at onset, male and
from a broad economic spectrum.
A serious condition is one that is uncontrollable, and includes psychological
features that impair normal functioning. Bulimia nervosa sometimes
develops in obese adolescents or following episodes of anorexia nervosa.
The disorder may also arise in adolescents with less fashionable hereditary
shapes, e.g. large or unusually shaped leg muscles. The adolescent
with bulimia is more likely to be fertile than the individual with anorexia
nervosa. Therefore, certain young women will have bulimia during
pregnancy (See section on Bulimia Nervosa in Pregnancy).
Bulimia Nervosa: Common psychosocial
Bulimia nervosa, a serious eating disorder, indicates important psychological
disturbances in the adolescent. Her self-esteem is often extremely
low and tied to her feelings about certain characteristics of her body
that are genetically controlled. She usually thinks of herself as physically
unattractive, although others may observe that she is well groomed and
has normal, even attractive, physical features. Normal weight adolescents
with bulimia obviously will not have the seriously compromised nutritional
status of those starving with anorexia nervosa. Thus, unlike adolescents
with anorexia nervosa, they will not experience the mental dysfunction
and distorted perception resulting from starvation neurosis (described
by Keys et al in The Biology of Human Starvation, U of Minn. Press, 1950,
vol. II). See section on Crisis
Stage: Psychological effects of starvation
Superficially, the adolescent with bulimia nervosa may keep a heavy
social schedule, but in reality she may have few close friends. In contrast
to the more rigid adolescent with anorexia nervosa, young women with bulimia
nervosa often demonstrate poor impulse control. By all accounts, gorging,
vomiting, and purging serve to release tension for the sufferers.
They often describe feeling “numbed out” during a binge. However,
the residual guilt and feelings of inadequacy bring renewed tension that
helps perpetuate an uncontrolled cycle. Social isolation is also
perpetuated because they fear their secret will be found out.
Bulimia Nervosa: Food related behavior
The teenager with bulimia nervosa periodically eats large amounts of food
and then voluntarily vomits, purges or exercises excessively. Each
person with bulimia nervosa defines a binge for herself. Because
of distortions in thinking about food, as little as one doughnut may be
thought of as a binge by one person while as much as an entire package
of doughnuts may constitute a binge for another. As the habits continue,
it becomes easier for adolescents to vomit. Eventually, the vomiting
is a nearly automatic response. In addition, an adolescent may abuse
laxatives to purge herself of the food she has ingested or use diuretics
to remove body fluid.
Bulimia Nervosa: Common physical symptoms
Physical symptoms of the adolescent with bulimia nervosa will include:
Life-threatening situations are rarer in adolescents with bulimia nervosa
than with anorexia nervosa. They are:
Cracked, damaged lips
Esophageal inflammation (all of the above symptoms are caused by exposure
of unprotected tissues to acidic vomitus)
Callused hands (from contact with teeth when used to stimulate vomiting)
Swollen salivary glands (caused by acidic reflux or constant stimulation)
Broken blood vessels in face (from force of vomiting)
Rectal bleeding (caused by overuse of laxatives)
Fluctuations in body weight
Dehydration and electrolyte imbalance
Ruptures in the upper gastrointestinal tract
Bulimia Nervosa: Dental destruction
Adolescents who regularly vomit due to an eating disorder will sustain
severe damage to dental enamel, most prominently on the lingual surface
of the teeth. A specific pattern of erosion of enamel, and even of
dentin, has been identified in frequent vomiters and described in detail.
Previously applied fillings will be left standing above the surface of
teeth that have been eroded. Dentists, may be the first health care
professionals in position to recognize an eating disorder if an adolescent
seeks improved dental esthetics. Dental specialists have developed
a protocol for prevention of further erosion, meanwhile referring adolescents
for eating disorder treatment. The strategy includes neutralizing
oral fluids following vomiting episodes and avoiding abrasion of the teeth.
Thus, adolescents are taught to use bicarbonate of soda washes and to refrain
from brushing after vomiting. Dentists supply fluoride as a preventive.
Meanwhile, to insure the restoration will be effective, restorative procedures
are delayed until adolescents are in treatment and have ceased vomiting.
Pain and discomfort in the oral cavity may interfere with normal eating
patterns adolescents need to adopt in order to recover from bulimia or
anorexia nervosa. Thus, the permanent teeth of adolescents need to
be protected by attentive clinicians of all disciplines who can refer them
to dentists familiar with the complexities of serving adolescents with
eating disorder syndromes.
Bulimia Nervosa: Intervention strategies
The techniques most frequently reported in treating adolescents with bulimia
nervosa are similar to those employed to promote recovery of anorexia nervosa
adolescents, including psychotherapy, nutritional therapy, medical monitoring
and health education. Pharmicotherapy may be included with other
modalities when providers determine it will improve overall treatment.
An experienced, well trained treatment team will be needed for greatest
Bulimia Nervosa: Psychotherapy
The emphasis of this component of psychotherapy is freeing the person from
guilt, facilitating gains in self-esteem, and helping her deal with anxiety.
Distorted goal setting linked to perfection or changing inherent body characteristics
is challenged. Ideally the adolescent’s family or partner will be included
in certain aspects of psychotherapy, though not as routinely as for anorexia
nervosa since adolescents are generally older.
Bulimia Nervosa: Nutritional therapy
While she deals with the psychological problem, the adolescent with bulimia
nervosa will need reeducation to nourish herself properly. Physical
and nutritional education can fill gaps in the knowledge of these teenagers
about their body functions. Over time, myths about weight management can
be dispelled and more normal eating habits developed. Because of distorted
feelings about food, the adolescent with bulimia may feel guilty every
time she eats, despite the fact that food is necessary to sustain life.
The family often reinforces her guilt with a misguided overfocus on food,
thinness and physical appearance. An adolescent with bulimia usually
attempts to restrict her food intake to match the “ideal” (generally restrictive)
plan she conceives for herself. Binges may thus arise from the natural
physical and psychological urge to end hunger, with an over compensation
for the deprivation earlier in the day.
Bulimia Nervosa: Role of the clinical
The clinical nutritionist on the interdisciplinary treatment team will
help a young person with bulimia nervosa understand the role of food in
life and accept a more realistic weight. Helping her understand energy
balance and nutrient functions as well as the effects or gorging, vomiting,
and purging is especially useful. Education must be done in a counseling
mode, allowing for gradual alteration of the adolescent's rigid set of
beliefs. Psycho-therapists will provide concurrent family and individual
psychotherapy, dealing with underlying causes of obsessional food behavior.
They may determine group therapy will be most effective at some stages
of recovery. Physicians will manage the physical care, monitoring
symptoms and progress.
Bulimia Nervosa: Coincident with pregnancy
If pregnant, the teenager with bulimia may be committed to protecting her
unborn child but retain ideas that inhibit normal nourishment of herself,
her fetus, and the child after birth. Physical concerns during pregnancy
are the adverse bio-chemical- chemical environment for the mother and fetus,
the mother’s abnormal weight gain pattern and the mother’s unrealistic
ideas about infant feeding. Weight loss, lack of weight gain or inordinate
gain during gestation, indicate adverse nutritional status. During
recovery, care of any pregnancy that may occur must be included.
Bulimia Nervosa: Pregnancy care
The teenager with bulimia nervosa who is pregnant can be helped to accept
the idea that the baby she wants must be adequately nourished. She is then
supported in retaining foods that the fetus needs. If she cannot give up
bingeing and vomiting, or purging, totally, she must be taught to delay
it until nourishing foods have been digested. Delaying detrimental
bulimic behavior is analogous to making sure an oral contraceptive is not
vomited out of the system, which sexually active adolescents who wish to
avoid pregnancy learn to do. All aspects of gestational progress
should be carefully monitored. The pregnant adolescent with bulimia
should also be helped to learn to recognize natural hunger signals from
her baby after it is born. Intensive therapy for an eating disorder,
building on skills the young woman developed to maintain health during
gestation, can begin post partum.
[ Nutritional Care Summarized - Table ]
This Web Site is a reference for health care professionals, students and
educators; it is not intended to provide advice or treatment to people with
eating disorders. If you have an eating disorder or disturbed eating
patterns, consult a qualified physician who specializes in eating disorders.