Bulimia nervosa afflicts mostly women (about 6% of adolescent girls,
and 5% of college women). Most individuals with bulimia engage in compensatory
activities such as vomiting, laxative abuse, strict dieting, and vigorous
The primary symptoms of bulimia are recurrent episodes of binge eating and compensatory measures to purge the calories. There is an excessive influence of the importance of the body and weight on one's self-evaluation (Negri).
Symptoms of bulimia can be quite invisible because the bulimic can maintain normal weight. Occasionally, patterns of behavior may signal a problem: Do they restrict certain food? Do they eat in a ritualistic way? Are they overly concerned with diet? Do they weigh themselves every day? Do large quantities of food disappear from the refrigerator? Do they visit the bathroom soon after meals or frequently? (Negri).
Some bulimics have a telltale scar on the first two knuckles of their
hand from inducing vomiting. Some purge themselves up to several times
a day. This can lead to serious medical consequences: dental cavities,
electrolyte imbalances, disturbances in heart rhythm and dangerously low
blood pressure (Negri).
Psychiatrist Linda Gochfield, who teaches brief psychotherapies to mental-health professionals, maintains that if people have a problem that responds to medication, that can be the briefest and most effective therapy of all (Davis).
While bulimia often occurs with comorbid mood disturbances, the treatment
benefit found for antidepressants in bulimia may not be merely alleviation
of depressive symptoms; the increased serotonin levels also help reduce
food intake. Looking at results of 14 studies of treatment of bulimia with
antidepressants, it has been noted that administration to bulimics agents
that increase the availability of serotonin virtually always produces better
results than placebo, regardless of the presence or absence of depression
There is now compelling evidence from double-blind, placebo-controlled
studies that antidepressant medication is useful in the treatment of bulimia
nervosa. What is less clear is which patients are most likely to benefit
from antidepressant medications and how to best sequence the various therapeutic
interventions available. The utility of antidepressant medications in bulimia
nervosa has led to their evaluation in binge eating disorder. The limited
information currently available suggests that antidepressant treatment
may be associated with a reduction in binge frequency in obese patients
with binge eating disorder, but does not lead to weight reduction. Additional
studies of the use of medication in the treatment of binge eating disorder
and of the role of pharmacotherapy in the treatment of bulimia nervosa
are needed (Devlin).
The results of psychopharmacological treatment studies of patients with
bulimia nervosa have overall been more favorable than those of anorexic
patients. Statistically significant effects concerning the reduction of
bulimic or depressive symptoms in bulimia nervosa has been demonstrated
for tricyclic antidepressants, serotonergic agents (Prozac), non-selective
monoamine-oxydase-inhibitors, and trazodone. The antibulimic effect appears
not to be associated with the antidepressant effect (Fichter).
The FDA recently approved the first drug, fluoxetine or Prozac, for
bulimia. Other medications have been found to be helpful for bulimia and
bingeing. Treatment for these disorders tends to be multi-modal. A treatment
team would include an internist or pediatrician, a psychotherapist, a nutritionist,
and possibly a psychopharmacolist and family therapist (Negri).
The Food and Drug Administration has approved Prozac for a new indication:
the treatment of bulimia nervosa. Bulimia is characterized by recurrent
episodes of binge eating, feelings of being out of control, and an obsession
with food and weight (Alexander).
"The great advantage of Prozac is its tolerability as compared
to the other classes of antidepressants--the tricyclics and the monoamine
oxidase inhibitors (MAOIs). Other selective serotonin reuptake inhibitors
(SSRIs) are presumed to work but have not been studied-nor have doing studies
been done for them," concluded B. Timothy Walsh, M.D., professor of
clinical psychiatry, College of Physicians and Surgeons, Columbia University
The FDA has ordered Pfizer Inc. to stop distributing sales brochures
to doctors and health-care institutions that the agency says were unapproved,
and in some cases possibly unsafe, uses of the drug Zoloft, its popular
antidepressant. A letter from the FDA to Pfizer CEO William Steere Jr.
cites the company for marketing Zoloft for treating premenstrual depression,
chronic low-grade depression, obsessive-compulsive disorder and postpartum
depression, uses not approved by the FDA (Langreth).
Turnbull and others examined pretreatment variables to predict outcome
in two treatments for bulimia nervosa. Those with more frequent bingeing
may require a more intense intervention, and those who have been ill longer
may be more motivated to respond to treatment (Turnbull).
The drug's approval as a therapy for bulimia was based on three double-blind,
placebo-controlled clinical trials. In the first two trials 387 women received
either 60 mg or 20 mg of fluoxetine or placebo. Patients were typical of
those requiring treatment, and all met DSM-III-R criteria for bulimia nervosa.
Median reductions in binge-eating episodes for the two eight week studies
were 67% for 60 mg fluoxetine, 45% for 20 mg fluoxetine, and 33% for placebo.
Vomiting episodes were reduced 56%, 29%, and 5%, respectively (Alexander).
Patient responses were divided into three levels according to reductions
in episodes: complete (100%), marked (75%-99%), and moderate (50%-74%).
For binge-eating episodes among women receiving the 60 mg dose, slightly
more than 20% were complete responders, slightly more than 15% were marked,
and slightly fewer than 15% were moderate. For vomiting, 16% showed complete
response; 12% and 22% showed marked and moderate responses respectively
Evaluation through the Eating Disorder Inventory or EDI also showed
a significant treatment benefit indicating a reduction in concern with
an extreme pursuit of thinness. Evaluations both by physicians and by patients
revealed significant improvement. Also, it was pointed out that the 60
mg dose is triple the recommended fluoxetine dose for depression (20 mg)
Pamela K. Keel and James E. Mitchell sought to synthesize existing data on outcome for individuals diagnosed with bulimia nervosa in order to better understand long-term outcome and prognostic factors.
Method: They reviewed 88 studies that conducted follow-up assessments with bulimic subjects at least 6 months after presentation. Findings are summarized for the areas of mortality, recovery, relapse, crossover, and prognostic variables.
Results: The crude mortality rate due to all causes of death for subjects with bulimia nervosa in these studies was 0.3 or seven deaths among 2,194 subjects; however, ascertainment rates and follow-up periods were small and likely to produce underestimation. Five to 10 years following presentation, approximately 50 of women initially diagnosed with bulimia nervosa had fully recovered from their disorder, while nearly 20 continued to meet full criteria for bulimia nervosa. Approximately 30 of the women experienced relapse into bulimic symptoms, and risk of relapse appeared to decline 4 years after presentation. Few prognostic factors have been consistently identified, but personality traits, such as impulsivity, may contribute to poorer outcome. In addition, participation in a treatment outcome study was associated with improved outcome for follow-up periods less than 5 years.
Conclusions: Treatment interventions may speed eventual recovery but
do not appear to alter outcome more than 5 years following presentation.
Long-term outcome for women diagnosed with bulimia nervosa remains unclear.
However, this disorder may be chronic for at least a subset of women (Keel).
This study used L. Benjamin's structural analysis of social behavior
(1974) rating scales to assess how perceptions of parental relationships
relate to self-concept. The results indicate that female patients with
bulimia perceive both parents as hostility disengaged. Furthermore, the
self-concepts of patients with bulimia were significantly associated with
perceptions of paternal attack or friendliness, which differentiated them
from control participants. The results were discussed in terms of the possible
relations between family factors and self-concept in bulimia (Klein).
This study presents data which suggests that fluoxetine is effective
in the treatment of bulimia nervosa. Two trials of unprecedented size (n=387
and 398, respectively) have recently been reported. These two studies show
that fluoxetine, 60 mg/day, has a clear beneficial effect on behavioral
and other (attitudinal) measures of bulimic symptomatology, and that this
dose of fluoxetine is well tolerated in patients with bulimia nervosa (Wood).
Predisposing factors for bulimia nervosa, according to B. Timothy Walsh,
M.D., professor of clinical psychiatry, College of Physicians and Surgeons,
Columbia University, New York City, include female gender, living in a
culture that emphasizes thinness, and familial obesity. A consistent precipitating
factor in bulimia is dieting. "Bulimia almost always first develops
in the course of a diet or right after," Walsh observed. Typically,
individuals have lost some weight and, after bingeing in response to hunger,
induce vomiting or one of the other compensatory mechanisms. "By the
time they come to a clinic, through a complex interaction of behavior,
psychology, and biology, they are caught in a cycle of bingeing and vomiting,"
he said (Alexander).
Once the cycle is established, enlarged gastric capacity--along with
other factors that may contribute to disturbed saiety, such as 5-HT receptor
changes, slowed gastric emptying, decreased cholecystokinin release, and
altered vagal activity--many reinforce the pattern. Foremost among physiologic
consequences are esophageal inflammation or tears, stomach emptying disorders,
and colon ruptures or dysfunction. Phychological effects include guilt,
isolation, impaired relationships, mood disturbances, and possible suicide.
The condition is often chronic, intractable, or relapsing (Alexander).
Alexander, Walter. "Prozac Wins New Indication: For Bulimia Nervosa."
Drug Topics 141 6 Jan. 1997.
Council, JR, MH Klein, and S. Wonerlich. "Relationship of Social
Perceptions and Self-Concept in Bulimia Nervosa." Journal of Consulting
& Clinical Psychology. 64(6): 1231-7, 1996 Dec.
Davis, Flora. "Medications: The Briefest Therapy?" Working
Woman 21 Feb. 1996.
Devlin, MJ and BT Walsh. "Pharmacotherapy of Bulimia Nervosa and
Binge Eating Disorder." Addictive Behaviors. 20(6): 757-64, 1995 Nov.-Dec.
Fichter, MM. "Drug Treatment of Anorexia Nervosa and Bulimia Nervosa."
[ Review]. Nervenarzt. 64(1): 21-35, 1993 Jan.
Keel, Pamela K. and James E. Mitchell. "Outcome in Bulimia Nervosa."
The American Journal of Psychiatry 154. Washington: March 1997.
Langreth, Robert. "Pfizer Ordered to Alter Claims for Zoloft Uses."
Wall Street Journal 7 Aug. 1996.
Negri, Gloria. "Q. & A. With Anne E. Becker, M.D., Eating Disorder
Specialist." Boston Globe: Boston, Mass. Feb. 2, 1997.
"Rx Pad: New Drugs, New Indications." Patient Care 31: Feb.
Turnbull, Susan J. "Predictors of Outcome for Two Treatments for
Bulimia Nervosa: Short and Long Term." International Journal of Eating
Disorders 21: Jan. 1997.
Wood, A. " Pharmacotherapy of Bulimia Nervosa--Experience with
Fluoxetine." International Clinical Psychopharmacology. 8(4): 295-9,
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