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diagnostic criteria for eating disorders
Bulimia Nervosa

The following clinical descriptions are taken from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
    1. Eating, in a discreet period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar 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. )
  2. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting , misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.
  3. The binge eating and other compensatory behaviors both occur, on the average, at least twice a week for three months.
  4. Self evaluation is unduly influenced by body shape and weight.
  5. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Purging Type: during the current episode of bulimia nervosa, the person has regularly engaged in self -induced vomiting or the misuse of laxatives, diuretics or enemas.
Non purging 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.

The term bulimia is derived from Latin and means, "hunger of an ox."
It is the bingeing that separates those with anorexia from those with bulimia even though both populations will restrict food consumption and many anorexics also purge. Individuals with anorexia who purge and normal weight individuals who do not binge but vomit whenever they eat food they consider "too fattening" are often improperly diagnosed with bulimia nervosa. Without binge eating a diagnosis of bulimia is not correct. The disorders do seem to cross over into each other. Many, if not most, people with bulimia have thought patterns and experience symptoms similar to those who have anorexia. The drive for thinness and the fear of being fat appear in both disorders and while body image distortion is present in bulimia, it is usually not to the degree as in anorexia nervosa.

Most people with bulimia restrict caloric intake such that they try to keep a weight that is too low for them to maintain without experiencing many of the symptoms of semi-starvation. Some with bulimia are at or above normal weight but nevertheless experience starvation symptoms due to the restriction of food intake when not binge eating. Some people who suffer from bulimia have a similar mind set to those with anorexia and repeatedly tried to control their weight by restricting. Eventually the restricting leads to bingeing and purging through self-induced vomiting, laxatives, or diuretics, to make up for the binge. Non purging bulimia involves individuals who try to control their weight by using other compensatory behaviors to make up for their binges, such as fasting, exercise, or other means.

Purging and other compensatory behaviors actually calms individuals with bulimia down and eases their guilt and anxiousness about having consumed too much food or gained weight. As the disorder progresses, individuals with bulimia will purge or compensate for eating even normal or small amounts of anything they consider "bad" or "fattening" and, eventually, any food at all. Binges can eventually be quite extreme. For example, binges of up to 50,000 calories a day have been recorded. A major university even claimed they had to put signs up in their dormitory bathrooms pleading, "Please stop throwing up, you're ruining our plumbing!" The acid from vomiting was ruining the pipes.

Bulimic behaviors begin as a result of trying to control weight and eventually become a means of affect regulation in general. A person with bulimia finds solace in food and often in the purging itself. The act of purging becomes powerfully addictive, not just because it controls weight, but because it is calming, or serves as a way of expressing anger, or in some other way helps the individual cope, albeit destructively.

In fact, individuals with bulimia seem to be individuals who need help regulating or modulating affect states and therefore are more prone to use a variety of coping mechanisms such as drugs, alcohol, and even sex.

Social functioning and adjustment among people with bulimia varies. For one thing, unlike those with anorexia, individuals with bulimia are not easily identified and are able to be successful at work, in school, and in relationships, while keeping the bulimia a secret. Patients have disclosed their bulimia to therapists after successfully hiding it from everyone, including their spouses, for 20 years. Some people with bulimia become so entrenched in the disorder, bingeing and purging 18 or more times per day, that they have little or no ability to perform on the job or in school and have marked difficulty with relationships.

Individuals suffering with bulimia are almost always distressed by their behaviors and at the same time are amazed, surprised, and even horrified at their own behaviors and their seeming inability to control them. They often talk about their bulimia as though they were not in control of it, possessed by something, or as if a monster were inside of them.

Because they feel ashamed of their behavior, out of control, taken over, and even possessed, people with bulimia often come into treatment seemingly more motivated than anorexics. Goals have to be carefully explored due to the fact that motivation to seek help may be generated only by the desire to stop bingeing and become better at losing weight. People with bulimia believe that bingeing is the root of their problem, the thing to be ashamed of and to control. It is common to express the desire to stop bingeing but be reluctant to give up restrictive dieting. Furthermore, individuals with bulimia believe that, if they could just stop bingeing, the purging would stop, so they assert their efforts to control their eating, thus setting themselves up again for a binge which is almost always secondary to the restricting. Unlike in bulimia nervosa, there are individuals for whom bingeing is the primary problem, and the compulsive consumption of food is due to causes other than restricting. These individuals, if they do not resort to some form of purging or restricting, suffer from Binge eating disorder.
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