Bulimia is defined as the compulsive absorption
large quantities of food, unrelated to hunger, and usually ending with spontaneous vomiting or more often provoked.This is a common condition and perhaps underestimated the extent that subjects who have it hide the access they are victims.
The prevalence of the disease was assessed in a meta-analysis by Makino in 2004: 0.3% to 7.3% among women and from 0 to 2.1% in men in Western countries, 0, 46 to 3.2% for non-Western women. In another meta-analysis in the Netherlands, the figures are 1% of young women and 0.1% among young men with an annual incidence of 12 cases per 100 000 inhabitants. In a prospective study conducted in Scandinavia in 2004, about 1,026 girls and 934 boys aged 14-15, the prevalence was at 1.2% in girls and 0.4% in boys.
TRACKING A BULIMIA:
Clinical picture:
It is usually poor. Patients are often normal weight and do not show their entourage of pathological signs that may alert. The food taken during shared meals, or not, is usually normal. Menstrual irregularities are fairly common but amenorrhea represents less than 10% of cases. Some small symptoms may attract attention: enlarged parotid glands, far from constant, small ulcers back metacarpals or phalanges, witness induced vomiting practices. But the subjects hide their condition and not in open when they can no longer endure psychologically.
Anorexia Bulimia Association is not very common. Both diseases can succeed in the history of the patients.
On rare anorexic, with a very low weight, have bulimic behaviors. The massive food intake is so pure as in bulimia without food, in secret. Cachectic anorexic ostensibly taking gargantuan meal they will vomit then do not participate bulimia as we see it here.
Own complications of bulimia:
Shareholders bulimia complications are rare. For some, the concomitant use of laxatives and / or diuretics in a desperate search of emptiness can lead Electrolyte disturbances, especially a source of intestinal paresis hypokalemia or even occlusion, and possible disorders serious heart rhythm.
ELEMENTS OF PATHOGENESIS:
Genetic studies:
eating disorders have been work for twenty years. However for bulimia, studies of twin pairs in particular have failed to highlight differences between homo- and heterozygous twins.
There would be no direct genetic predisposing factor. In contrast, compared to a control group, there is much more affective disorders in bulimic families, three or four times more common among first-degree relatives, while the difference is not significant for the families of anorexics.
Psychosocial factors:
Psychosocial factors also play a less said for anorexia nervosa role.
Certainly social glorification of thin can affect negatively, but the real bulimic access are the result of an impulse somehow addictive more than a weight concern. Nevertheless, once the heap of calories swallowed, vomiting, sometimes helped laxative, is not fat.
Bulimic personality of the subject:
The subject’s personality bulimic is marked by constant anxiety, the frequency of depressive tendency and addictive traits.
Anxiety is shameful, and bulimic as long as possible hiding a practice which they derive no pride. These disorders can evolve periods, times when bulimia is most present corresponding to downturns on itself greater.
Patients often feel but rarely express a feeling of total lack of self-control, because of autodévaluation added.
These traits are shared with many addicts, and bulimia can be likened to an addiction to food. A study of Flament in 1999 has also shown that in France over 300 bulimics, 37% used one or more substance, first anxiolytics for one third of them, but also alcohol and illegal drugs.
This personality is built in families with affective disorders are often present. Marital conflict and divorce are more frequent there and harder than in the general population. In any case, patients often feel that their role in life is to hold together a father and a mother who otherwise would separate. The experience of traumatic experiences of childhood is also more common than in a control population. This is sexual abuse noted by Vanderlinden in the history of 18% of bulimics (against 10% of restrictive anorexia).
ASSOCIATIONS, DIFFERENTIAL DIAGNOSIS:
Associations:
We have seen the relationship between bulimia and substance abuse. Dysregulation endorphinic was raised in bulimia where we noted lower endorphin levels in the cerebrospinal fluid (CSF) compared to controls, this decline is also correlated with the depression scale. The interpretation of these facts is not simple.
The relationship between bulimia and intensive physical or sporting practices can be explained by the endorphin system. The study of 1,696 Norwegian top athletes showed in 2004 a significantly higher prevalence of eating disorders including bulimia compared to controls. Of the 113 non-professional dancers studied in 2003 in Florence by Rivaldi include 2.7% of bulimics, a figure statistically higher than in matched controls.
Differential diagnosis:
There is not, as the symptoms of the disease is special. It cites possible and transient confusion with early schizophrenia, and some very rare neurological diseases Kleine-Levin syndrome (hypersomnia and polyphagia) and Kluver-Bucy syndrome, bilateral temporal lesion that is associated with hyperphagia, of PICA and sexual disinhibition.
TREATMENT AND PROGNOSIS:
Treatment:
Often the bulimic patient decides to see a doctor because the situation has become intolerable. The approach is fragile and listen to the doctor must not fail. The quality of this first contact is very important.
While it is excellent, the patient can go back and hide in his depression, anxiety and shame. The consultation will in this case at least allowed that the wire is not broken and that effective therapy can take place later.
Psychotherapy:
Psychotherapy is obviously very important.
In milder cases, it may be provided by the family doctor. A psychiatric opinion is often useful. And in many cases, a true psychiatric treatment is necessary. Cognitive behavioral therapy, psychoanalytic approaches (sometimes a little more tolerant as to the method) are used depending on the case and the skills of the therapist.
Medical treatment:
Antidepressants:
Antidepressants are the most used. They are inhibitors of serotonin reuptake now commonplace. Many studies have shown that fluoxetine significantly decreased (over 50%) the frequency of binge eating, regardless or not of its effect on the mood of patients. Other molecules in the same family have also been used successfully, fluvoxamine and more recently citalopram. These drugs tend to supplant the tricyclics (imipramine, desipramine, etc.) who had also obtained a reduction in the number of seizures.
AEDs:
Antiepileptic drugs may also be useful. Green and Rau had in 1974 suggested that bulimic crises could be considered as variants of seizures. By 1977, phenytoin had been used with non always confirmed results.
Two recent studies challenge to date these treatments. Hedge, in 2003, showed that, against placebo, topimarate caused a decrease in the number of access but also an improvement in self-esteem, body image and anxiety.Zonisamide (not yet available in France) tends to lose weight and is also active in bulimia.
Other molecules:
Other molecules have been tried. Naltrexone has been tested in the 1990s at doses up to 300 mg. The effectiveness joined hepatotoxic doses! Ondansetron has achieved notable results in three small studies. Both classes of drugs have been used in view of the pathogenic role of endorphins and serotonin (genes, receptors) in eating disorders.
Prognosis:
Evolution is often marked by alternating better and relapses, more or less related to the therapeutic moment. The long-term prognosis has been some recent work. Jager, in 2004, studied 80 German bulimics with a decline of 5 to 7 years.
Over 60% of them do not have any eating disorder and have a normal family and professional adaptation. These good results were not found in Taiwan where the contrary 56% of patients still present after 10 years of eating disorders.
All studies join to say that few patients, less than 5%, pass bulimia the restrictive anorexia.
A 2003 meta-analysis indicates that “a large group of bulimics become chronic condition and suffers from severe bulimia symptoms and social and sexual disturbances.” This difficult evolution is marked by suicide attempts in a quarter of patients, often severe and / or multiple, but rarely fatal.
However, after 11.5 years of follow-up work done on 173 women with bulimia noted that 74.6% of them had completed at least one pregnancy, and only 1.7% had reported an infertility problem, not different numbers from those of the reference population.
Mortality at 10 years of bulimia is not different either from controls.
Few prognostic factors were identified.
The long-term evolution does not depend, it seems, of precocity of the treatment, but the severity of the psychological context of patients and the quality of therapeutic care.
