1. eating, in a discrete 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)

B. 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.

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 Anorexia Nervosa.

Specify type:

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

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

Understanding Nausea and Vomiting

Bulimia Nervosa, like anorexia nervosa, has received so much media attention, that much like with anorexia, chronic vomiting after meals is now viewed by the general public as always being caused by mental illness, namely, an eating disorder.

Few public awareness campaigns or best-selling books on the subject have made any mention that nausea and vomiting are common symptoms of many chronic diseases. It is sobering to realize that all the behaviors typical of bulimia nervosa can be induced by physical illness.

Vomiting is a very unpleasant experience, and can cause many undesireable complications. It is entirely possible for an individual with a medical disorder to feel nauseated after eating, and not realize it is due to disease. A young person who is informed on eating disorders will more likely think they are developing an eating disorder rather than being physically sick.  Regardless whether the bulimic patient is highly motivated to lose weight, chronic vomiting, even if self-induced, should always raise the suspicion of disease before the diagnosis of BN is considered. 

Many medical disorders can also cause chronic constipation or edema, which may motivate the patient to overuse laxatives and diuretics. Since the majority of young women these days are intensely self-conscious regarding their weight, the vomiting and laxative abuse is often assumed to be an effort to lose weight.

Vomiting is an extremely unpleasant experience, yet whenever someone experiences nausea, vomiting generally relieves the nausea and the patient actually feels better. If no attempt is made to identify and treat the underlying medical disorder, chronic vomiting may ensue, and the patient may become convinced they are developing an eating disorder.

Medical Disorders That Can Cause Nausea:

Before a diagnosis of bulimia nervosa can be made, all medical illness that can cause nausea and vomiting must be ruled out. This can only be done through a comprehensive patient examination and extensive diagnostic testing.

Here are a few medical disorders that can cause nausea and vomiting:

Peptic Ulcer, cholecystitis, cholelithiasis (gallstones), pancreatitis, Crohn's disease, gastritis, celiac disease, ulcerative colitis, diverticulosis, gastroenteritis, hepatitis, gastroesophogeal reflux disease, hiatal hernia, appendicitis, alcoholism, uremia, chronic obstructive lung disease, pregnancy, intestinal obstruction, gastrocolic fistula, gastric outlet obstruction, gastroparesis, migraine headache, motion sickness, meniere's disease, renal failure, liver failure, metabolic acidosis, adrenal insufficiency, hypothyroidism, food poisoning, medications, diabetes mellitus, hyponatremia, hypercalcemia, hyperkalemia, ruptured viscus, peritonitis, paralytic ileus, biliary colic, pancreatic cancer, meningitis, etc. Obviously some of these will be easy to rule out. Others will require extensive testing (see page on medical tests).

In some cases, psychotherapy may help a patient to develop techniques for avoiding vomiting. Certainly, each of us through willpower and concentration can often override and somewhat conrol the vomit reflex. The accountability of being in an eating disorder program may also motivate a patient to suppress the urge to vomit. However, if the underlying medical disorder is not addressed, it is unlikely the patient will be able to suppress the urge indefinitely. 

Some medical disorders, like peptic ulcer disease, may come and go, and if no attempt is made to identify the underlying medical problem, recovery may actually be due to remission of the ulcer, even though the patient and the therapist may be convinced it is a result of psychotherapy.

Bingeing Behavior

Bingeing may be a normal adaptive response to caloric restriction (i.e. dieting)  and may not indicate disease (see page on starvation response). However, when it is paired with chronic vomiting, disease should be suspected. Hypoglycemia may also play a part in developing food cravings and bingeing behavior. For some, self-induced vomiting may be a maladaptive method of controlling the insulin response.  Some medications may also induce food cravings and weight gain as a side effect.

Conclusion

Diagnostic testing is vital to ruling out any differential diagnosis when bulimia nervosa is suspected. If the attending physician does not pursue this avenue, the patient may suffer for years in an eating disorder program where the underlying illness won't be addressed.

What are your experiences with Bulimia Nervosa or chronic vomiting? Contact us and let us know!