BULIMIA (PDF)

Bulimia AI Bulimia INT 8/5/02 1:27 PM Page 1  Other books in the At Issue series: Alcohol Abuse Animal Experimentation Anorexia The Attack on America: September 11, 2001 Biological and Chemical Weapons The Central Intelligence Agency Cloning Creationism vs. Evolution Does Capital Punishment Deter Crime? Drugs and Sports Drunk Driving The Ethics of Abortion The Ethics of Genetic Engineering The Ethics of Human Cloning Heroin Home Schooling How Can Gun Violence Be Reduced? How Should Prisons Treat Inmates? Human Embryo Experimentation Is Global Warming a Threat? Islamic Fundamentalism Is Media Violence a Problem? Legalizing Drugs Missile Defense National Security Nuclear and Toxic Waste Nuclear Security Organ Transplants Performance-Enhancing Drugs Physician-Assisted Suicide Police Corruption Professional Wrestling Rain Forests Satanism School Shootings Should Abortion Rights Be Restricted? Should There Be Limits to Free Speech? Teen Sex Video Games What Encourages Gang Behavior? What Is a Hate Crime? White Supremacy Groups AI Bulimia INT 8/5/02 1:27 PM Page 2  Bulimia Daniel Leone, President Bonnie Szumski, Publisher Scott Barbour, Managing Editor Loreta M. Medina, Book Editor San Diego • Detroit • New York • San Francisco • Cleveland New Haven, Conn. • Waterville, Maine • London • Munich AI Bulimia INT 8/5/02 1:27 PM Page 3  © 2003 by Greenhaven Press. Greenhaven Press is an imprint of The Gale Group, Inc., a division of Thomson Learning, Inc. Greenhaven® and Thomson Learning™ are trademarks used herein under license. For more information, contact Greenhaven Press 27500 Drake Rd. Farmington Hills, MI 48331-3535 Or you can visit our Internet site at http://www.gale.com ALL RIGHTS RESERVED. No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution or information storage retrieval systems—without the written permission of the publisher. Every effort has been made to trace the owners of copyrighted material. Bulimia / Loreta M. Medina, book editor. p. cm. — (At issue) Includes bibliographical references and index. ISBN 0-7377-1164-7 (alk. paper) — ISBN 0-7377-1163-9 (pbk. : alk. paper) 1. Bulimia. I. Medina, Loreta M. II. At issue (San Diego, Calif.) RC552.B84 B84 2003 616.85'263—dc21 2002069733 Printed in the United States of America LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA AI Bulimia INT 8/5/02 1:27 PM Page 4  Contents Page Introduction 6 1. Bulimia Nervosa: An Overview 10 Beth M. McGilley and Tamara L. Pryor 2. Testimony of a Recovered Female Bulimic 17 Sandy Fertman 3. Bulimia in Older Women 23 Susan Chollar 4. Men Are Becoming More Vulnerable to Bulimia 28 Lisa Liddane 5. Adolescence: Setting the Stage for Eating Disorders 32 Marlene Boskind-White and William C. White Jr. 6. Bulimia May Be Linked to Sexual Abuse 40 Jennifer Redford 7. Bingeing and Dieting as Methods of Coping with Pain 46 Becky W. Thompson 8. Bulimia Is on the Rise Among Nonwhite Populations 54 Kathryn J. Zerbe 9. Current Approaches to Treating Bulimia 60 Carolyn Costin 10. The Role of Parents in a Child’s Recovery 67 Abigail H. Natenshon Organizations to Contact 71 Bibliography 75 Index 77 AI Bulimia INT 8/5/02 1:27 PM Page 5  6 Introduction In recent years the incidence of bulimia in the United States has in- creased: The American Psychiatric Association estimates that today 1.1 to 4.2 percent of females will have bulimia in their lifetime. Many health professionals have expressed concern that bulimia, together with ano- rexia, binge eating, and other eating disorders may soon reach epidemic proportions. The Washington-based National Eating Disorders Associa- tion, which claims to be the largest advocacy and prevention organiza- tion in the world, estimates that 5 to 10 million girls and women and 1 million boys and men are battling some form of eating disorder in the United States. Of those suffering from bulimia in the country, 90 to 95 percent are fe- male. Most troubled are college-age women, teens, middle-aged women, and more recently, children. Among men, the most vulnerable are athletes, fitness enthusiasts, and those who have experienced various kinds of abuse, causing them to succumb to anxiety and, oftentimes, low self-esteem. The fourth edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, published in 1994, defines bu- limia as an eating disorder that involves episodes of binge eating and purging and lack of control over eating. To avoid gaining weight from huge food intakes, a bulimic person engages in self-induced vomiting and often misuses laxatives, diuretics, enemas, or other medications. He or she may also engage in fasting and compulsive exercise. The binge eating and the compensatory behavior occur at least twice a week for three months. Bulimics generally have normal body weights, but they are never satisfied with them. Having an ideal weight in mind, their overriding goal is to become thinner. Bulimics usually binge on high-calorie junk foods like fast food, ice cream, french fries, sweets, and cookies, with calorie intake per binge run- ning from one thousand to twenty thousand—way over the standard. One school of thought suggests that bulimia occurs more in developed countries because of higher intakes of processed carbohydrates. In con- trast, developing and poorer countries mostly rely on whole grains and vegetables, which are always more healthful. Most of a bulimic’s routine is spent in finding the time and place to indulge in his or her uncontrollable habit. The person caught up in the disorder follows the cycle of bingeing and purging at home, at work, in a college dorm, at parties, during the day, and at night. The bulimic often feels shame, loneliness, isolation, guilt, and terror but finds it hard to break the cycle of eating and disgorging, eating and fasting, eating and laxatives, eating and compulsive exercise. The habit can even lead the in- dividual to periodic lying and, in many cases, stealing; after all, mounds of food could cost a lot of money. Avoiding social activities, the bulimic rarely has meaningful friendships and intimate relationships. AI Bulimia INT 8/5/02 1:27 PM Page 6  Introduction 7 The initial signs and symptoms of bulimia are sometimes misleading: vomiting, diarrhea, scarring of the fingers and hands, constipation, and menstrual irregularities. Often, this delays proper detection, which brings further harm to a suffering individual. Many health providers also note that many sufferers tend to deny the symptoms of the disorder. Repeated vomiting could lead to erosion of tooth enamel, dehydration, stomach ul- cers, and eventually an imbalance in electrolytes, which could be life- threatening. Serious consequences include kidney damage, ruptured stomach or esophagus, irregular heartbeat, and seizures. Finally, bulimia can cause death from a damaged heart or loss of body chemicals. Author Debbie Stanley observes in her book Understanding Bulimia Nervosa that together with other eating disorders, bulimia and its twin, anorexia (which involves avoiding food to the point of starvation), account for more deaths than any other psychiatric condition. Indeed, while its manifestations are physical, bulimia—again, like anorexia—is a mental disorder. A bulimic person suffers from abnormally low self-esteem, a desire for perfection, heightened loneliness and isola- tion, and an obsession with food. He or she is also prone to depression and anxiety. A bulimic shares several similarities with an anorexic: an ob- session with diet, a distorted body image, a lack of self-esteem, and a sense of inadequacy. Both are likely young women who come from middle-class families with dominant mothers and uninvolved fathers. Hungry for approval, both bulimics and anorexics tend to become “duti- ful daughters” and comply with family rules. Yet whereas an anorexic avoids food and is always starved, a bulimic is always on a cycle of binge- ing and purging. A bulimic is also capable of a social and work life while an anorexic often is not. The causes of bulimia in women—like anorexia and other eating dis- orders for that matter—have been initially attributed to a culture that stresses and rewards female thinness as well as to the mass media, which promote irrational standards of beauty. The Harvard Eating Disorders Center (HEDC) cites a study of children aged eight to ten wherein half of the girls and one-third of the boys reported being dissatisfied with their body size. The most dissatisfied among the girls wanted to be thinner, and the dissatisfied boys wanted to be heavier. Another study showed that expectations regarding thinness among young girls are evident as early as six and seven years old. In terms of actual dieting, HEDC cites a study of 457 fourth graders in which 40 percent reported dieting “very of- ten” or “sometimes.” Another study on dieting indicated that 31 to 46 percent of nine-year-olds and 46 to 81 percent of ten-year-olds reported dieting, fear of fatness, and binge eating. It is disturbing that eating disorders may soon be afflicting more and more children and teens, and recent research on the nature of eating dis- orders does not offer relief either. Most studies point out that eating dis- orders are much more complex than a simple obsession with weight ex- pressed in the misuse of food. Often the disorder is a mask for—if not a response to—deeper, far more serious psychological pathologies. Various research surveys have found sufferers to be dealing painfully with issues of self-worth, dysfunctional family relationships, unresolved conflicts, and traumatic childhood experiences. In many ways, bulimia is a coping mechanism employed during times of duress. Jennifer Redford, writing in AI Bulimia INT 8/5/02 1:27 PM Page 7  8 At Issue Physician Assistant in March 2001, cites numerous studies that link bu- limia and sexual abuse in childhood. Initially, studies have pointed to the most vulnerable group as young white middle-class women who are inclined toward traditional values such as successful careers and marriage. Marlene Boskind-White, a professional counselor who has helped thousands of bulimia sufferers on college cam- puses, observes that bulimic women are often attractive, bright, talented, and have potential for creative activity such as writing, dancing, painting, and acting. Also, they are able to pursue careers and often become over- achievers. In Bulimia Anorexia: The Binge/Purge Cycle and Self-Starvation, Boskind-White and coauthor William C. White Jr. explain the sufferer’s drive as a compensation for her shortcomings. Based on their practice, the two authors note that a bulimic’s pursuit of success is not for the joy of achievement but for the expected rewards, particularly from men. More recent research shows that sufferers are no longer confined to the white middle-class female population. Growing evidence suggests that bulimia among non-Caucasians—including Native Americans, His- panics, African Americans, and Asians—is on the rise. Kathryn Zerbe, a psychoanalyst and a former faculty member at the Karl Menninger School of Psychiatry, attributes this to the aforementioned groups’ improved so- cioeconomic conditions, exposure to media stereotypes, and, more im- portantly, their vulnerability to destabilizing life change such as immi- gration, acculturation, and westernization. Merry N. Miller and Andres J. Pumariega, both professors of the de- partment of psychiatry at the James H. Quillen College of Medicine, East- ern Tennessee State University, echo the link between bulimia and socio- cultural change. Writing in Psychiatry in the summer of 2001, they note that eating disorders such as bulimia occur when traditional ideas of physical attractiveness are threatened and supplanted with something else. The two authors also identify the changing role of women as a ma- jor factor. Supporting this contention, Karin Kratina, a dietician and con- sultant for Renfrew Center, which treats eating disorders, is quoted by Jim McCaffree in the Journal of the American Dietetic Association as saying, “Cultures that experience oppression of women in conjunction with in- creased expectations of women tend to have more incidences of eating disorders.” Becky Thompson, a sociologist and author, refutes the common con- tention that eating disorders are about women’s vanity. Through in-depth interviews with a group composed of African Americans, Hispanics, and lesbians, she found that women resorted to eating disorders as a way of dealing with poverty, racism, alienation, sexism, and sexual abuse. Re- garding the alienation that some groups may be experiencing, the HDEC cites a study involving 135 males with eating disorders that indicated that 42 percent of those diagnosed as bulimic were either gay or bisexual. Another group that has been succumbing recently to eating disorders in bigger numbers is immigrant girls and women. Quoted in the March 6, 2000, issue of the Washington Post, Catherine Steiner-Adair of Harvard Uni- versity’s Eating Disorder Center says that one-fourth of her clients have been American teenagers whose parents were born in Latin America, Africa, the Middle East, and Asia. In their desire to blend into their communities, these women may be trying too hard to fit into the American ideal of thin- AI Bulimia INT 8/5/02 1:27 PM Page 8  ness. To respond to the phenomenon, youth centers in places like Los An- geles and New York have started support groups for immigrants. Acknowledging that eating disorders are, for the most part, a social problem, scholars like Miller and Pumariega propose that care providers should offer more carefully crafted programs of prevention and treat- ment. They stress that strategies have to strengthen personal identity, reach out more strongly to women of color and other disenfranchised groups, promote rational ideals of beauty, and reinforce adaptive prac- tices. A meaningful program would also require clinicians to work across cultural differences and include the influence of traditional beliefs in their interventions. While modes of treatment continue to evolve with the recognition that eating disorders are both medical and psychiatric concerns, re- searchers continue to unravel new information. A recent study in Britain found that bulimia springs partly from a deficiency in tryptophan, a chemical in the brain. Tryptophan, an amino acid that occurs naturally in many foods, is used by the body to make serotonin, which in turn reg- ulates mood and appetite. In a 1999 New York Times article, lead re- searcher Katharine A. Smith of Oxford University said that the finding suggests that “lowered brain serotonin function can trigger some of the clinical features of bulimia nervosa in individuals vulnerable to the dis- order.” (In the same manner, anorexia nervosa is being studied on its pos- sible link to a gene. The Eating Disorder Program of the University of Pittsburgh Medical Center Health Systems is participating in an interna- tional study that seeks to determine whether a gene or a set of genes might predispose individuals to develop anorexia nervosa.) As eating disorders continue to spark more attention, as new research sheds new light on their nature, and as professionals continue to search for effective strategies for prevention, advocacy, and treatment, a better understanding of the issue may emerge, resulting in positive responses from various sectors. When this happens, more suffering individuals may come forward and seek help. Hopefully, millions of suffering women, children, and men—not to mention their families and communities—will be able to find solace and relief. Introduction 9 AI Bulimia INT 8/5/02 1:27 PM Page 9  11 Bulimia Nervosa: An Overview Beth M. McGilley and Tamara L. Pryor Beth M. McGilley and Tamara L. Pryor codirect the eating disorder clinic at the University of Kansas School of Medicine in Wichita, where they are both faculty members. Beth M. McGilley maintains a private practice. Tamara L. Pryor is clinical associate professor in the Depart- ment of Psychiatry and Behavioral Sciences and a member of the Man- aged Care Task Force of the Academy of Eating Disorders. Bulimia nervosa, more popularly known as bulimia, afflicts three percent of young women in the United States. It is considered a mental or psychiatric disorder with physical manifestations that include episodes of eating binges, followed by purging to prevent weight gain. It is also often accompanied by fasting, excessive ex- ercise, and the misuse of diuretics, laxatives, or enemas. In severe cases, a victim may suffer from dental erosion, swollen salivary glands, gastrointestinal irritation, and loss of body fluids. Sufferers of this illness should be referred to a mental health professional with specific expertise in eating disorders. By evaluating a patient’s medical condition, attitudes and behaviors, developmental his- tory, and interpersonal relationships, a professional can deter- mine the most appropriate treatment for the patient. B ulimia nervosa is a psychiatric syndrome with potentially serious con- sequences. Relatively effective treatments for this disorder have been developed, and early intervention is more likely to facilitate eventual re- covery. Unfortunately, few health care professionals receive training in the assessment of bulimia nervosa. Therefore, they may be unable to identify and treat patients with the disorder. Historically, patients with bulimia nervosa often were hospitalized un- til the most disruptive symptoms ceased. In today’s health care environ- ment, hospitalization for bulimia nervosa is infrequent and tends to take the form of brief admissions focused on crisis management. Specialists in the field of eating disorders have responded to the present cost-containment From “Assessment and Treatment of Bulimia Nervosa,” by Beth M. McGilley and Tamara L. Pryor, American Family Physician, June 1998. Copyright © 1998 by the American Academy of Family Physicians. Reprinted with permission. 10 AI Bulimia INT 8/5/02 1:27 PM Page 10  measures by developing a combination of treatment modalities, including medication and individual and group psychotherapy, that can be used in the outpatient care of patients with bulimia nervosa. This article discusses the assessment and treatment of bulimia nervosa and considers how this disorder can best be handled in a managed care environment. Bulimia nervosa is a multifaceted disorder with psychologic, physio- logic, developmental and cultural components. There may be a genetic pre- disposition for the disorder. Other predisposing factors include psychologic and personality factors, such as perfectionism, impaired self-concept, affec- tive instability, poor impulse control and an absence of adaptive function- ing to maturational tasks and developmental stressors (e.g., puberty; peer and parental relationships, sexuality, marriage and pregnancy). Bulimia nervosa is a multifaceted disorder with psychologic, physiologic, developmental and cultural components. Biologic researchers suggest that abnormalities of central nervous system neurotransmitters may also play a role in bulimia nervosa. Fur- thermore, several familial factors may increase the risk of developing this disorder. For example, researchers have discovered that first- and second- degree relatives of individuals with bulimia nervosa have an increased in- cidence of depression and manic-depressive illnesses, eating disorders, and alcohol and substance abuse problems. Regardless of the cause, once bulimia nervosa is present, the physio- logic effects of disordered eating appear to maintain the core features of the disorder, resulting in a self-perpetuating cycle. Diagnosing bulimia The diagnostic criteria for bulimia nervosa (Table 1) now include subtypes to distinguish patients who compensate for binge eating by purging (vomiting and/or the abuse of laxatives and diuretics) from those who use nonpurging behaviors (e.g., fasting or excessive exercising). A binge eating/purging subtype of anorexia nervosa also exists. Low body weight is the major factor that differentiates bulimia nervosa from this subtype of anorexia nervosa. Thus, according to the established di- agnostic criteria, patients who are 15 percent below natural bodyweight and binge eat or purge are considered to have anorexia nervosa. Patients can, and frequently do, move between diagnostic categories as their symptom pattern and weight change over the course of the illness. Some patients do not meet the full criteria for bulimia nervosa or an- orexia nervosa. These patients may be classified as having an eating dis- order “not otherwise specified.”. . . Prevalence of bulimia Bulimia nervosa appears to have become more prevalent during the past 30 years. The disorder is 10 times more common in females than in males Bulimia Nervosa: An Overview 11 AI Bulimia INT 8/5/02 1:27 PM Page 11  12 At Issue and affects 1 to 3 percent of female adolescents and young adults. Both anorexia nervosa and bulimia nervosa have a peak onset be- tween the ages of 13 and 20 years. The disorder appears to have a chronic, sometimes episodic course in which periods of remission alternate with recurrences of binge/purge cycles. Some patients have bulimia nervosa that persists for 30 years or more. Recent data suggest that patients with subsyndromal bulimia nervosa may show morbidity comparable to that in patients with the full syndrome. The long-term outcome of bulimia nervosa is not known. Available research indicates that 30 percent of patients with bulimia nervosa rapidly relapse and up to 40 percent remain chronically symptomatic. Psychiatric conditions related to bulimia Clinical and research reports emphasize a frequent association between bulimia nervosa and other psychiatric conditions. Comorbid major de- Table 1: Diagnostic Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within a two-hour pe- riod), an amount of food that is definitely larger than most people would eat during a similar period of time and under sim- ilar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to pre- vent weight gain, such as self-induced vomiting; misuse of laxa- tives, diuretics, enemas, or other medications; fasting or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of an- orexia nervosa. Specific types: • Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the mis- use of laxatives, diuretics, or enemas. • Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994: 549–50. AI Bulimia INT 8/5/02 1:27 PM Page 12  pression is commonly noted (Table 2), although it is not clear if the mood disturbance is a function of bulimia nervosa or a separate phenomenon. Information concerning the comorbidity rates of bipolar disorders (e.g., manic depression, rapid cycling mood disorder) and bulimia ner- vosa is somewhat limited. However, recent epidemiologic data indicate an increased incidence of rapid cycling mood disorders in patients with more severe, chronic bulimia nervosa. The association between bulimia nervosa and other anxiety and substance-related disorders has been well documented. For example, sub- stance abuse or dependence, particularly involving alcohol and stimu- lants, occurs in one third of patients with bulimia nervosa. Thus, a co- morbid substance-related disorder must be addressed before effective treatment for bulimia nervosa can be initiated. Significant research has been devoted to the high frequency of per- sonality disturbances in patients with bulimia nervosa. Overall, between 2 and 50 percent of women with bulimia nervosa have some type of per- sonality disorder, most commonly borderline, antisocial, histrionic or narcissistic personality disorder. To ensure that the treatment approach is properly designed and ef- fective, the physician must look carefully for symptoms of comorbid psy- chiatric illness in patients with bulimia nervosa. Although further re- search is needed to determine the extent to which comorbid conditions influence the course of bulimia nervosa, the presence of these additional problems clearly complicates the treatment process. Medical complications The medical complications of bulimia nervosa range from fairly benign, transient symptoms, such as fatigue, bloating and constipation, to chronic or life-threatening conditions, including hypokalemia, cathartic colon, impaired renal function and cardiac arrest. . . . Binge eating alone rarely causes significant medical complications. Gastric rupture, the most serious complication, is uncommon. More of- Bulimia Nervosa: An Overview 13 Table 2: Psychiatric Conditions Commonly Coexisting with Bulimia Nervosa • Mood disorders: major depression, dysthymic disorder, and bipo- lar disorder. • Substance-related disorders: alcohol abuse, stimulant abuse, and polysubstance abuse. • Anxiety disorders: panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, and post-traumatic stress disorder. • Personality disorders: borderline personality disorder, histrionic per- sonality disorder, narcissistic personality disorder, and antisocial personality disorder. AI Bulimia INT 8/5/02 1:27 PM Page 13  ten, patients describe nausea, abdominal pain and distention, prolonged digestion and weight gain. The combination of heightened anxiety, physical discomfort and in- tense guilt provokes the drive to purge the food by self-induced vomiting, excessive exercise or the misuse of ipecac, laxatives or diuretics. These purgative methods are associated with the more serious complications of bulimia nervosa. Self-induced vomiting Self-induced vomiting, the most common means of purging, is used by more than 75 percent of patients with bulimia nervosa. Most patients vomit immediately or soon after a binge. During the binge, they commonly drink excessive fluids to “float the food” and facilitate regurgitation. Bulimia nervosa appears to have become more prevalent during the past 30 years. Vomiting is induced by stimulation of the pharynx using a finger or a narrow object such as a toothbrush. Some patients describe the learned ability to vomit by pressure or contraction of the abdominal muscles. A minority of patients develop reflux following the consumption of virtu- ally any amount of food or fluid. Treatment of this reflux is difficult and requires that the patient practice relaxation during food ingestion. Self-induced vomiting can lead to a number of serious medical com- plications. • Dental Erosion. Gastric acids may cause deterioration of tooth enamel (perimolysis), particularly involving the occlusal surfaces of molars and the posterior surfaces of maxillary incisors. Since these effects are irreversible, patients with this complication need to have regular dental care. • Enlarged Salivary Glands. Frequent vomiting has been reported to cause swelling of the salivary glands in approximately 8 percent of patients with bulimia nervosa. The exact etiology is unknown. The glandular enlargement is typically painless and may occur within several days of excessive vomiting. It appears to be a cosmetically distressing but medically benign condition. Other than cessation of vomiting, no specific treatment has been identified. • Oral and Hand Trauma. The induction of vomiting with a finger or an object can cause lacerations of the mouth and throat. Bleeding lacerations can also occur on the knuckles because of repeated con- tact with the front teeth. Some patients with bulimia nervosa de- velop a calloused, scarred area distal to their knuckles. Oral or hand trauma can provide evidence of vomiting even when patients deny bulimic symptoms. • Esophageal and Pharyngeal Complications. Because of repeated contact with gastric acids, the esophagus or pharynx may become irritated. Heartburn and sore throats may occur and are best treated with antacids and throat lozenges, respectively. 14 At Issue AI Bulimia INT 8/5/02 1:27 PM Page 14  • Blood in the vomitus is an indication of upper gastrointestinal tears, which are a more serious complication of purging. Most tears heal well with cessation of vomiting. Perforation of the upper di- gestive tract, esophagus or stomach is an extremely rare but poten- tially lethal complication. Patients with gastric pain and excessive blood in their vomitus should be evaluated on an urgent basis. • Electrolyte Imbalances. Serious depletions of hydrogen chloride, potassium, sodium and magnesium can occur because of the exces- sive loss of fluids during vomiting. Hypokalemia represents a po- tential medical emergency, and serum electrolyte levels should be measured as part of the initial evaluation in all new patients. Pa- tients who complain of fatigue, muscle spasms or heart palpitations may be experiencing transient episodes of electrolyte disturbance. Paresthesias, tetany, seizures or cardiac arrhythmias are potential metabolic complications that require acute care. Chemistry profiles should be obtained regularly in patients who continue to vomit or abuse purgatives on a regular basis. Assessment and treatment Since bulimia nervosa has numerous medical complications, a complete physical examination is imperative in patients with this disorder. The ex- amination should include vital signs and an evaluation of height and weight relative to age. The physician should also look for general hair loss, lanugo, abdominal tenderness, acrocyanosis (cyanosis of the extremities), jaundice, edema, parotid gland tenderness or enlargement, and scars on the dorsum of the hand. Routine laboratory tests in patients with bulimia nervosa include a complete blood count with differential, serum chemistry and thyroid pro- files, and urine chemistry microscopy testing. Depending on the results of the physical examination, additional laboratory tests, such as a chest radiograph and an electrocardiogram, may be indicated. Finally, patients who engage in self-induced vomiting should be referred for a complete dental examination. Between 2 and 50 percent of women with bulimia nervosa have some type of personality disorder. Because of the multifaceted nature of bulimia nervosa, a comprehen- sive psychiatric assessment is essential to developing the most appropri- ate treatment strategy. Patients should be referred to a mental health pro- fessional with specific expertise in this area. Frequently, student health programs or university medical centers have personnel who are experi- enced in the evaluation and treatment of eating disorders. . . . The most appropriate course of treatment can usually be determined on the basis of a thorough evaluation of the patient’s medical condition, associated eating behaviors and attitudes, body image, personality, devel- opmental history and interpersonal relationships. In the present managed care environment, hospitalization for pa- Bulimia Nervosa: An Overview 15 AI Bulimia INT 8/5/02 1:27 PM Page 15