Psychopathology Sum-Up: Bulimia Nervosa

[This is a guest post by Tetyana Pekar]

Tetyana is about to defend her MSc in Neuroscience at the University of Toronto. She is passionate about making eating disorder research more accessible to the public. She writes the Science of Eating Disorders blog where she aims to make sense of the latest findings in eating disorder research for lay audiences. She can be reached at tetyana@scienceofeds.org.

What is bulimia nervosa?

Bulimia nervosa (BN) is a serious eating disorder (ED) characterized by cycles of bingeing and compensatory behaviors. The most common compensatory behaviour is self-induced vomiting, but others include laxatives, diuretics, fasting, and excessive exercise. It is a common misconception that all BN patients self-induce vomiting—not so, while most do, there is a sizeable minority that does not (Keski-Rahkonen et al, 2009).

Individuals with BN are typically normal weight or overweight. This isn’t by chance; it is almost by definition. If someone binges and purges but is underweight, they will most likely be diagnosed with anorexia nervosa (AN) binge/purge subtype. Importantly, these diagnostic categories are not static, distinct groups, as over 50% of those diagnosed with restricting type AN cross over to bingeing/purging type within 5 years of ED onset, and about one-third cross over to BN (Eddy et al. 2008). So, take these diagnostic categories with a grain of salt.

Prevalence & Mortality

EDs have a high mortality rate, but keep in mind that prevalence and mortality statistics always depend on the duration of the study, the study size, and the population studied (among other things). However, most studies converge on a lifetime prevalence of BN somewhere between 1-2% (0.9-1.5 among women and 0.1-0.5% among men) (Smink et al., 2012).

The standardized mortality ratio (bulimia patients/normal, age-controlled population) for BN varies from ~2-5 (Arcelus et al., 2011). In one study of 906 individuals with BN, 3.9% died in the mean follow-up of 19 years, with suicide accounting for 23% of those deaths (Crow et al., 2009).

Causes

As much as people like the point the finger at the media and ‘thin culture,’ this explanation cannot be the whole story. After all, we are all exposed to images of thin models, and yet only 1-2% of women experience BN at some point in their lives. What is it about this percentage of women that makes them susceptible to BN?

Certainly, genetics plays a role.

Family studies are useful for determining if a particular disorder aggregates in families, though they cannot decipher if that aggregation is due to genetic risk factors of shared environmental factors (such as an over-emphasis on weight and appearance). These studies have shown that first-degree relatives of BN patients have a 4.4-9.6 higher likelihood of having BN than relatives of healthy controls (Kassett et al., 1989; Stein et al., 1999; Strober et al., 2000; ).

Twin studies are another good way to delineate the effects of genes and environment. These studies have shown that between 54-83% of the variation we see in BN is accounted for by genetic effects (Bulik et al. 1998, 2010; Kortegaard et al. 2001; Wade et al. 1999). (Note, this DOES NOT mean genes cause 54-83% of the disorder.)

This does not mean there are genes for BN (genes code for proteins, after all). However, commonly occurring temperament and personality traits might account for some of the genetic risk factors. Traits such as perfectionism, obsessionality, sensitivity to reward and punishment, and impulsivity often occur before ED onset and persist following recovery for many patients (Kump et al., 2004).

In addition, neurotransmitter systems, such as serotonin and dopamine, appear to modulate a lot of the traits associated with eating disorders. Indeed, serotonin might play an important function in the development of BN (and, along with the effects of estrogen, might partly explain why females are much more likely to suffer from EDs than males.)

It is almost important to emphasize that EDs are not “Western” disorders that arise solely due to an overemphasis on thinness. To provide just a few examples, blind women are not immune to EDs, and Iranian women living in Tehran exhibit similar levels of disordered eating behaviours as their counterparts in Los Angeles.

Behaviour does not occur in a vacuum. Genetics and environment both play a role. (For more on causes, see this post.)

Comorbidities

Eating disorders are generally highly comorbid with depression and anxiety disorders (Blinder et al., 2006). As mentioned earlier, patients with eating disorder tend to score high on perfectionism, neuroticism, impulsivity (particularly for BN patients), harm avoidance and obsessive-compulsive disorder. Among BN patients, the most common personality disorder appears to be borderline personality disorder (Sansone et al., 2005).

Treatment & Outcomes

Treatment for BN can include outpatient, inpatient, and/or residential treatments, among other things. As readers of FtB are well aware, any hard to treat diseases and disorders always attract pseudoscientific treatments. So, what treatments are evidence-based?

SSRIs, interestingly enough, have been shown to be effective in reducing the frequency of bingeing and purging in BN patients compared to placebo, particularly fluoxetine/Prozac (reviewed in Flament et al., 2012 and Hay et al., 2012). Cognitive-behavioural therapy is also widely considered to be an evidence-based treatment for BN (though, I have my reservations) (Murphy et al., 2010). In the end, the most important thing is to have a strong therapeutic alliance between the patient and the treatment team/therapist, as well as motivation to change.

In terms of outcomes, the results depend on length of follow-up, duration of illness, and sample population (i.e., how sick are the patients?). However, one large review found that about 45% of BN patients fully recovered, 27% improved, and 23% had a chronic course (Steinhausen et al., 2009).

Problems with the DSM

Compared to the problems with anorexia nervosa (AN), there are not as many. However, here are two things that annoy me:

  • Arbitrary frequency and duration criteria (2x/week for 3 months) (This will be reduced to 1x/week in the DSM-V.)
  • Too focused on weight (“compensatory behavior in order to prevent weight gain” and “self-evaluation is unduly influenced by body shape and weight”). These can certainly be true, but they don’t have to be. Bingeing and purging can just be a tool to regulate emotions.

Common Myths

Here are some other common myths that I haven’t mentioned yet:

  • BN patients throw up everything they eat. No, but some do, sometimes. The frequency and extent of behaviours varies a lot.
  • BN patients should just eat 5-small meals a day. Well, yes, but the problem has got nothing to do with not knowing how to eat well in theory.
  • BN is on the increase. Actually, studies suggest is pretty stable or even decreasing.
  • It is an effective weight control method (i.e., it is safe). I suppose, if you are okay with the plethora of medical complications (including death).

And one that bothers me the most:

  • BN is just about vanity. Actually, for me, bingeing and purging is incredibly anxiety reducing, and I’m usually symptomatic when I’m stressed, overwhelmed, or feel like crap about myself (not productive enough, for example). A sense of calmness and tranquility often follows self-induced vomiting (and I’m not alone in feeling this way).

Hopefully I’ve covered the basics. If you want to know more about BN, feel free to ask me questions in the comments, send me an email or check out BN-related posts on my blog here.


Tetyana was diagnosed with restricting type anorexia when she was in grade 10, started bingeing and purging at the end of first year in university. Her eating disorder has been all over the place, and she enrolled in outpatient treatment in high-school. She will be attending Women in Secularism conference. (Where I finally get to meet her!) You can follow her on Twitter.

Previous Psychopathology-Sum Ups:

Specific Phobias
Bipolar Disorder
Types of Antidepressants

Happy Valentine’s Day! Surly Amy: Citation Needed

Photo on 2-14-13 at 6.19 PM

It’s more a graduate school sort of necklace than a Valentine’s one, but I got it today so!

Go buy her awesome stuff.

Screen Shot 2013-02-14 at 6.42.11 PM

Musical Wednesdays: A comment and ukulele song for Pope Ratzinger

It’s been a very long time since I’ve allowed myself to do video commentary on YouTube.  I once had a vlog and it was so thoroughly abused by assholes that I took it down.  But, I am short of time lately and it’s less difficult to just sit and talk than to carefully construct an article that I found the video to be the better format for my anger at Child Abuse Supporter Joseph Ratzinger.  Here’s a comment and song just for him:

FULL OF BAD WORDS

Monday Miscellany

The pope is gone! Paul Fidalgo wants to replace him.

Oh, and I’ll put an immediate end to the church’s tolerance and enabling of sexual assault; its treatment of women as second-class; its adherence to Bronze Age notions of morality; its hoarding of wealth for no purpose but its own aggrandizement (except for me, of course); its persecution of homosexuals; its intentional miseducation of developing nations ravaged by ignorance, overpopulation, superstition, starvation, and illness; and its utter failure to promote the ascension of robot-human hybrids.

On the curse of the good girl, and how we socialize women to be malleable at their own expense:

Don’t get me wrong, I’m all for empathy, generosity, and kindness. But being a Good Girl isn’t about basic human decency.

It’s about inauthenticity and inequality. It’s about forcing girls and women into a mold of sweetness and light where they must repress their needs and bite their tongues in order to be perpetually “nice.”

Nico Lang would like you to stop being a jerk to your queer friends.

One queer/trans* perspective on having an eating disorder:
*Note: this is one perspective–not How It Works For Everyone(tm).

Being trans* was a significant complicating factor in my perceptions of my body—it’s just that I wasn’t aware that people could have a gender that was not “man” or “womyn” (predicated, of course, on being “male” and “female”-bodied, respectively) until I was in my early twenties. What I understood at the time as a simple desire to be very thin was actually more about purging what I saw as the “female” parts of myself.

Valentine’s Day is coming–so here’s a heartbreaking piece. A Valentine for My Gay Ex-Husband:

Libby Anne on the Abortion Wars–working as a clinic escort.

Add more links in the comments! (Extra points if they’re things you’ve written.)

Forward Thinking: What Would You Tell Teens About Sex?

Libby Anne and Dan Fincke have been running a project called Forward Thinking. Prompts are proposed, and bloggers can respond. Every two weeks a roundup of links is published.

The most recent topic is what we should be telling teenagers about sex. Being as I was a teenager a very short six months ago, I have Thoughts and Feelings about this. Lots of them. My own sex education (in Texas) wasn’t all so hot. Like, seriously, I would have thought abstinence-only education would be all about asexuality–“Some people don’t really think sex is the most interesting! See! It’s not worth trying!”–but nooooo. So, this is what I’d tell teenagers about sex and relationships. 

You don’t have to know who or what you like right now. But if you do, you get to feel exactly that way and anybody who frowns or corrects you or says its stupid or gross or weird should be frowned at the way you frown at your feet when you step in dog poo. Because that’s actually gross, and loving people isn’t.

Speaking of which, you don’t actually have to love everybody you do sexy things with. I’d like them to be people you trust and people who know what consent is and like communication, but you don’t have to love them. Kissing is fun and bodies are nice and hooking up with people who have especially nice bodies or brains or who are just friends with exactly enough time and singlehood on their hands is fun.

Condoms break. Getting Plan B is scary. Sometimes the pharmacy is out or closed or the person at the counter looks like the math teacher who was always cranky. Just buy some ahead of time, so the two of you can just fish it out of whomever’s nightstand and take a deep breath.

Just like some people prefer pistachio ice cream, you can have sexual preferences. You can like fat bodies, thin bodies, muscly bodies, femme men, femme women, women who like to be tied up, and people who only have sex in missionary. But it’s worth considering if the only reason you like pistachio ice cream is because that’s all the shops have been telling you is worth buying. Because that doesn’t mean some genius somewhere isn’t making brilliant raspberry sorbet that you could realize is five times better, if only you examine your pistachio conditioning.

Anyone who describes any part of your body as gross doesn’t deserve to see you naked. They don’t get to negotiate this.

The baseball metaphor sucks. Not only does everyone disagree on what each base actually stands for (your euphemism is a failure when you have to argue about what every part means), but it ranks things. Some people can take or leave P-I-V–or, you know, their partnerships don’t include one penis and one vagina–and some think oral sex is the best thing ever. And some people would actually rather be playing baseball.

Shaming people is stupid and uncreative. This applies equally to shaming people for all the sex they are having, and shaming people for all the sex they’re not having.

Monogamy is not required, but honesty and communication are.

Mostly, I want teens to know that adults aren’t always right–and one of the ways we’re very good at being wrong is in talking to adolescents about sex. This is also perhaps the first time that your beliefs and actions can be something your family considers morally wrong, repugnant, or unnatural…and that’s really scary. Luckily, if everybody is consenting and legal, you’re probably in the right.

Which leads me to the last thing–consent. This is actually the most important thing, and I’m okay with you rolling your eyes and ignoring my too-old-to-understand advice if you listen to this.

More of my female friends and acquaintances have been assaulted, coerced, or raped than not. I’m not estimating–that’s the reality that this college student sees. One of my friends rapists still lives in this town. I run into him frequently. He hasn’t, and probably won’t, suffer any consequences for his actions.

You must get consent for everything, every time. I don’t care if it’s painfully awkward to ask if they’re into it, if they want to go further. If a little bit of blushing is scary enough to move you from Consensual Sex-Haver to rapist, you shouldn’t be doing anything with anyone.

 –

Also, despite everything I ever heard…you can also write about sex on the internet without the Earth exploding.

What would you tell teens?

Musical Wednesdays: To the Moon and Back on Ukulele

Did you know that the band Savage Garden named itself after a line in an Anne Rice vampire book?  True story.  Did you know that Anne Rice once exchanged e-mails with me?  ALSO A TRUE STORY.

As Wednesday is the traditional day of the Karaoke, I celebrate with a musical selection just for you.

Ashley Speaking in Chapel Hill Next Monday

If you are in the Raleigh, Durham, Chapel Hill area and like Freethought Blogs and/or me and/or the topic of social justice movements and religion, then have I got good news for you!

I will be speaking at UNC-CH for their SSA (Secular Student Alliance) and SAGA (Sexuality and Gender Alliance) groups.

Monday, February 11, 2013
6:30pm until 8:30pm
Murphey 116, UNC

“Come out to hear Ashley Miller, a writer and tv/film editor, speak about religion’s interaction with women’s, gay, and minority rights, both the costs and benefits of religion to individuals in those groups, and how atheism as a movement has failed to be as strong an ally as they can be and how we can change that.

SSA and SAGA members are welcome to join us with Ashley for dinner before the event! “

Social Media Science

As a social scientist and nerd who works in the social media industry (yes, it is an industry), a recent story really caught my attention.  There’s been some claims that Google works better to follow/predict the flu than the CDC, but it turns out that Twitter is even better.

A couple of things

1. Here is a brilliant post summarizing the treatment that many women in the secular movement have faced in the last several years and the negative effects of that treatment.

http://www.secularwoman.org/opportunity_%20and_%20access_freethought

It’s a great piece, I am only jealous that I did not write it.

2. If you scroll down the page a bit until you get to Events — right above that is a place where you can donate money to FreethoughtBlogs.  As you may or may not know, everyone here blogs because they love it and tries to make time for it between their day job(s), school, and real life.  But, if you’d like to support FtB, and don’t feel obligated, I’m just pointing it out, there are some options to do so in the sidebar.

Two things, there you go.

Marriage as protection against accidental pregnancies not a new argument

Greta has a post up about the “increasingly stupid” tactics used by supporters of DOMA and Prop 8 — but, for better or for worse, the argument that marriage is different for heterosexuals because of accidental pregnancy is not a new argument at all.  It is, in fact, the primary argument used by the proponents in the original Prop 8 case.

I know, because the first time I ever got published in a “big space” was on Salon, for writing about this argument.

And Greta’s not the only one pointing to this — Rachel Maddow’s blog did as well.  Not that it isn’t worth pointing out, it definitely is, but it is even more worth pointing out that in the two and a half years the lawyers have had since the closing arguments of Prop 8 they’ve been unable to come up with anything more compelling.  Ouch.

Here was Judge Walker’s response at the time:

And [marriage], as Mr. Olson described this morning, is a right which extends essentially to all persons, whether they are capable of producing children, whether they are incarcerated, whether they are behind in their child support payments. There really is no limitation except, as Mr. Olson pointed out, a gender limitation.

Good news for us, bad for them.