Bipolar4LifeSupport

Introduction[1]

Parasomnias may be defined as undesirable disorders of behaviour or experience that occur during sleep or its specific stages, or during sleep-wake transitions. Common behavioural problems include unwelcome verbal outbursts or movements.
•Primary parasomnias arise without an underlying physical cause and may be classified by the stage of sleep in which they occur, as rapid eye movement (REM), non-REM (NREM) or miscellaneous (no specific stage affected). They are also classified diagnostically on the basis of their characteristic presentation.
•Secondary parasomnias are disorders caused by accompanying physical/psychiatric disturbance leading to sleep-related symptoms, eg seizures, cardiac dysrhythmia or dysfunction, respiratory dysfunction and gastro-oesophageal reflux.
•Dyssomnias such as insomnia, in contrast, are disorders of the initiation, timing, quality, maintenance or phasing of sleep and are not usually associated with aberrant behaviour or experiences.
•Night terrors and sleepwalking are sometimes called arousal parasomnias.
•Sleep disorders are being reported more often as they become more recognised and deemed as suitable conditions for treatment by the medical profession.[2]
•Two disorders recently described are somnambulistic sexual behaviour, or sexsomnia and sleep-related eating disorder.
•A Turkish survey of pre-adolescent school-aged children found a 14.4% prevalence of parasomnias. About 1 in 6 children had at least one parasomnia. Bruxism (grinding of teeth), nocturnal enuresis (considered by some to be a parasomnia) and night terrors were the most common types.[3]

Risk factors

One study found that arousal parasomnias were associated with sleep apnoea, alcohol intake at bedtime, mental disorders, shiftwork, excessive need for sleep, and stress.[4]

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Nightmare disorder[1]

This is synonymous with dream-anxiety attacks. Bad dreams/nightmares occur in REM sleep, with associated severe anxiety and symptoms of increased sympathetic outflow. There is complete alertness and recall of dreams on waking.The presence and recollection of the dream is what helps to differentiate this condition from night terrors. Sufferers may have experienced previous trauma that is relived. This presentation is a major symptom of post-traumatic stress disorder.

Epidemiology

Prevalence in children aged 3-5 years is estimated at 10-50% with an unknown adult prevalence. Up to 50% of adults report occasional nightmares.

Prognosis

Most children outgrow nightmare disorder but a small proportion may suffer into adulthood, with improvement in later life.

Night terrors[5]

This is synonymous with sleep terror disorder. The condition occurs with increased frequency in some families, suggesting a genetic predisposition. Disordered arousal occurs during NREM sleep, causing extreme panic and loud screams/movement. A sudden arousal from non-dreaming sleep occurs, usually about 90 minutes or so after falling asleep. There is often an accompanying scream or shout. There may be symptoms of increased sympathetic outflow. Initially, the patient may be unresponsive and tends to be confused, disorientated and unable to recall what has caused them to wake up. There may be nonsense or indistinct speech and bed-wetting. The sufferer may hit/throw objects or leave the bedroom. There is little or no subsequent recall of events.

Epidemiology

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) estimates prevalence at 1-6% in children, although recurrent episodes are less common. Adult prevalence is estimated at 65 years.[1][10]

For further details of presentation, associated diseases, management and prognosis, see the separate article Restless Legs Syndrome.

Assess family history of similar problems, recent changes in drug regimen or new over-the-counter/complementary preparations, drug or alcohol misuse, recent life events, nocturnal urinary function or any concerns/worries that may be pressing on the patient, such as debt, relationship difficulties or psychiatric disturbance. A review of prescribed or non-prescribed medicines that the patient is taking may give clues as to the type of disorder in question, or any pharmacological factors that are provoking or worsening parasomnia.

Signs

There are no specific physical signs of any of these conditions. Mental state examination should be predominantly normal. Significant abnormalities in mental state suggest a psychiatric condition causing a secondary parasomnia. REM sleep behaviour disorder patients (or their bed partners) may show signs of injury.

It is important to carry out a full screening physical examination in order to detect any other underlying disease that may be disturbing sleep and causing a secondary parasomnia, or precipitating RLS, eg signs of neuropathy/spinal cord disease.

Differential diagnosis[1]
•Generalised anxiety disorder.
•Panic disorder.
•Obstructive sleep apnoea.
•Post-traumatic stress disorder.
•Undiagnosed or decompensated physical illness, eg heart failure leading to paroxysmal nocturnal dyspnoea, neuropathy/myelopathy causing restless legs.
•Undiagnosed/relapsing psychiatric illness.
•Epileptiform disorders, especially temporal lobe epilepsy.
•Fugue states.
•Hypnagogic or hypnopompic phenomena (abnormal experiences associated with falling asleep or waking up).
•Alcohol or other drug misuse/withdrawal.

Investigations[1]

No specific investigations are needed unless there is reason to suspect an underlying physical condition causing a secondary parasomnia. In such cases, the following may be helpful:
•Electroencephalograph (EEG)/CT/MRI scanning for temporal lobe epilepsy.
•CXR/echocardiography for suspected heart failure.
•Investigations/referral for suspected obstructive sleep apnoea.
•In those with RLS/PLMD, an FBC to exclude iron deficiency anaemia is worthwhile.
•In older patients with RLS/PLMD, or new-onset REM sleep behaviour disorder, screening tests such as U&E, LFTs and TFTs and others may be considered useful to exclude physical diseases common in this age group.
•Patients with atypical or confusing presentations may benefit from referral to a sleep clinic for polysomnography to reach a definitive diagnosis.
•PLMD has a characteristic EMG pattern if recorded during sleep episodes.

Associated diseases[1]

REM sleep behaviour disorder has been associated with Lewy-body and other dementias, Parkinson’s disease,[11] subarachnoid haemorrhage, ischaemic cerebrovascular disease, olivopontocerebellar degeneration, multiple sclerosis and brain stem neoplasms.[1] A recent association with narcolepsy has also been discovered.[8]

There appears to be an association between parasomnias in early life and the later development of vitiligo. This is thought to be related to an abnormality of the serotoninergic neural system.[12]

There is an association between night terrors and sleepwalking and families with a predisposition for one condition also have an increased incidence of the other. There is also a link between both conditions and nocturnal frontal lobe epilepsy.[5]

Night terrors in children are not associated with psychopathology but in adults they can be associated with post-traumatic stress disorder and generalised anxiety . Dependent, schizoid and borderline personality disorders are also more prevalent.

For all parasomnias, medication side-effects, toxicity or withdrawal due to prescribed or non-prescribed medication should always be borne in mind.

Management[1]
•Most parasomnias require no definitive treatment other than explanation, reassurance of the sufferer and their family/bed partner and an offer to follow things up.
•Information leaflets (see Internet and further reading section, below) are a relatively easy and effective way of achieving this.
•Once parents of children with terror disorder have been appropriately informed and reassured, the vast majority can cope with the condition and it will usually resolve. Keeping a sleep diary may help to identify trigger factors.[5]
•Most night terrors resolve with time and without treatment. Treatment of comorbidities such as sleep breathing disorders may be helpful. Promoting a regular sleep pattern in a stable environment is important.There is little evidence that sedative medication is helpful in the long-term management of children with night terrors and other sleep disorders. Tricyclics are occasionally used for severe symptoms or where the condition affects daytime performance (eg at school).[5]
•Patients with underlying physical or psychiatric disease may benefit from adjustment of their treatment or specialist input to help ameliorate sleep-related symptoms.
•REM sleep behaviour disorder is usually treated with nocturnal benzodiazepines such as clonazepam and tricyclic antidepressants, where there is some evidence for their efficacy.[8]
•The successful treatment of sexsomnia with selective serotonin reuptake inhibitors (SSRIs) has been reported.[7]
•Levodopa/carbidopa, gabapentin and clonidine are sometimes used but there is little systematic evidence of benefit. Management in the context of dementia/Parkinson’s disease can be difficult and may require expert elderly medicine/psychogeriatric input.

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Complications[1]
•Accidental injury.
•Overeating during sleepwalking, leading to obesity.
•Relationship difficulties.
•Forensic consequences of behaviour during sleepwalking, particularly if the patient ventures into the outside world or displays sexual behaviour.

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Prevention[1]

Sufferers should avoid precipitants, particularly medications, caffeine, alcohol or sedatives, especially at night. One study suggested that an increase in sleep disorders was more prevalent in children who shared a bed, or a bedroom. Precautions against physical and potential legal consequences of disturbed nocturnal behaviour should be considered.

http://www.bipolar4lifesupport.co on line support group

Psychiatric disorders during pregnancy and following delivery are common:[1]
•For the majority of women who develop mental health problems during pregnancy, this is usually a mild depressive illness, often combined with anxiety.
•Pregnancy protects against developing a serious mental illness (schizophrenia, bipolar disorder and severe depressive illness) but is not protective against relapses of pre-existing serious mental illness, especially where usual medication has been stopped at the outset of pregnancy.
•Women who have had a previous episode of a serious mental illness, either following childbirth or at other times, are at an increased risk of developing a postpartum onset illness even where they have been well during pregnancy and for many years previously. This risk is estimated as at least 50%.
•Pregnancy was thought to have a protective effect on maternal suicide rate but Confidential Enquiries into Maternal Deaths have shown that whilst suicide during pregnancy remains relatively uncommon, suicide is a leading cause of maternal death. The majority of suicides occur following childbirth. Over half of women who died from suicide had a previous history of serious mental illness.

Women with mental health problems during pregnancy often feel stigmatised and good therapeutic relationships need to be built up. Ideally, women of reproductive age with pre-existing significant mental health problems should be encouraged to discuss pregnancy plans, enabling preconceptual counselling and medication review. Treatment decisions can be challenging, as risks and benefits need to be considered in terms of the welfare of mother and fetal dyad. Much research focuses on neonatal outcome, but neglects to consider maternal need.

General points

National Institute for Health and Clinical Excellence (NICE) guidelines[2] place emphasis on:
•Person-centred care – taking account of individual needs and preferences.
•Good communication with the patient, their family and carers and the provision of information that is accessible across any barriers such as language, culture or disability.
•Consent and capacity – due regard should be given to the prevailing legislation and guidelines on consent,[3] including the Mental Health Act and the Mental Capacity Act.[4] Treating adolescent patients can raise additional issues such as Fraser-Gillick competence, child protection concerns, and the Children Act.
•Early detection – enquiry regarding past psychiatric history and family history of perinatal mental illness at first contact with services in the antenatal period screening for depression.
•Initial management – where a serious mental health illness is suspected or has been diagnosed: •Consult with/refer to specialist mental health colleagues. Specialist multidisciplinary perinatal teams should be available in all areas to provide direct services, consultation and advice to maternity services, other mental health services and community services.
•Ask about mental health at all subsequent consultations.
•Develop a written care plan in collaboration with the patient, her family, carers and specialist mental health services which should deal with the management of the condition in pregnancy, delivery and the postnatal period. This should be recorded in all copies of the patient’s notes (ie those held in primary and secondary care, and hand-held obstetric notes).

•Lower thresholds for access to psychological treatments – ideally, pregnant women should be seen for treatment within a month of initial assessment, and no longer than 3 months afterwards.[2] This target reflects the changing risk-benefit ratio for psychotropic medication over this time.

Individual conditions[2]

Depression

See separate article Depression in Pregnancy.

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Generalised anxiety disorder and panic disorder
•For patients planning a pregnancy or presenting with an unplanned pregnancy, consider withdrawing existing medication and referring for cognitive behavioural therapy (CBT). Use a lower risk drug if medication is required.
•Patients with a first attack of generalised anxiety disorder (GAD) during pregnancy should be offered CBT.
•Patients with a first attack of panic disorder in pregnancy should be offered CBT, self-help or computerised CBT (C-CBT) prior to considering drug treatment.

Obsessive-compulsive disorder
•For patients with obsessive-compulsive disorder (OCD) who are planning a pregnancy or are already pregnant, consider withdrawing medication and starting psychological therapy.
•For patients with OCD who are not already on medication, psychotherapy should be considered first-line.

Post-traumatic stress disorder[5]
•For patients with post-traumatic stress disorder (PTSD) planning a pregnancy or already pregnant, withdraw medication – usually an antidepressant – and offer trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy.[6]
•Olanzapine is sometimes prescribed in cases resistant to a selective serotonin reuptake inhibitor (SSRI) but should not be given in this circumstance.

Eating disorders
•Anorexia: •Follow the NICE guidance on eating disorders.[7] This recommends assessment and psychological therapy in an outpatient setting wherever possible. In severe cases, inpatient treatment may be required for re-feeding.
•Medication used in anorexia may include antipsychotics, tricyclic antidepressants, macrolide antibiotics, and some antihistamines.

•Binge eating: patients who are planning a pregnancy or already pregnant should be treated as per depression.
•Bulimia: for patients planning a pregnancy or already pregnant, consider withdrawing medication gradually. If the problem persists, refer for specialist treatment. Women taking high-dose fluoxetine should be advised not to breast-feed.

Bipolar disorder[8]
•This is classified as a serious mental disorder but is now thought to encompass a spectrum of conditions. The first episode usually occurs before the age of 30.[9] Pregnant women with bipolar disorder are more likely to discontinue treatment, often in an unplanned and abrupt way, with the risk of relapse or recurrence in women not on treatment in the postpartum period as high as 50%. All women with a history of bipolar disorder should be under the care of psychiatric services whilst pregnant and in the postpartum period, and a high level of vigilance and close monitoring is required.
•Stable patients planning a pregnancy should remain on a typical or atypical antipsychotic if the risk of relapse is high but a low dose should be chosen. Monitor for weight gain and gestational diabetes in pregnancy.
•If mild-to-moderate depression returns after stopping prophylactic medication, CBT should be offered. Moderate-to-severe depression may need antidepressant treatment (quetiapine alone, or SSRIs, but not paroxetine) combined with CBT. Patients with bipolar disorder starting antidepressant treatment should usually also be on prophylactic treatment and be monitored closely for signs of mania or hypomania. The risk of manic switching is higher with tricyclics than SSRIs.
•If a patient with an unplanned pregnancy is taking lithium, an antipsychotic should be substituted.
•If a patient develops an acute episode of mania during pregnancy, check compliance with prophylactic medication and institute or increase the dose as appropriate.
•In the event of treatment failure and severe mania, consider electroconvulsive therapy (ECT), lithium or, rarely, valproate. If valproate has to be prescribed, consider augmenting with other anti-manic medication (except carbamazepine).

PatientPlus o

Depression in Pregnancy
Postnatal Depression
Postnatal Care (Puerperium)
Depression

Schizophrenia
•This is a major psychiatric disorder which affects about 1 in 100 people, and it usually first presents in the 20-30 age group.
•It should be treated in line with the NICE guidance on schizophrenia,[10] except that patients on an atypical antipsychotic should be switched to low-dose haloperidol, chlorpromazine or trifluoperazine.

Substance misuse

Mental health problems, such as depression, anxiety or personality disorders, frequently coexist with alcohol or drug misuse. Individuals with ‘dual diagnosis’, particularly in the context of a pregnancy, will need increased support and integrated services. Substance misusers may be late bookers or erratic users of antenatal care. Screening and recognition of substance misuse is not uniform and many problems go undetected.

Alcohol

Alcohol is teratogenic and fetotoxic, causing fetal alcohol syndrome and other congenital abnormalities. Its use is associated with increased rates of miscarriage and preterm labour and intrauterine growth restriction, although there are important confounding factors. Royal College of Obstetricians and Gynaecologists (RCOG) guidelines state:[11]
•The safest approach may be to avoid any alcohol intake during pregnancy, particularly during the first trimester, but there is no evidence of harm from low levels of alcohol consumption (≤1-2 units/week).
•Binge drinking appears particularly harmful.
•Better alcohol history taking is needed to identify the high-risk group of women with problem drinking. No biochemical test is recommended to provide an objective assessment of chronic alcohol use.
•Counselling and detoxification services should be easily accessible to women. As for heavy drinkers in general, motivational interviewing, CBT and brief interventions are thought to be effective. Very little evidence regarding alcohol detoxification in pregnant women is available but severe withdrawal symptoms are risky to both mother and fetus. Expert opinion suggests inpatient detoxification with IV benzodiazepine cover.

The risks of drugs to maintain abstinence (acamprosate, naltrexone, disulfiram) are not known in pregnancy so they are not currently recommended.

Opioids[12]

The prevalence of heroin use amongst pregnant women is thought to be 1-2% but may be much higher in some areas. Opioid misuse is associated with a much increased risk of obstetric (eg low birthweight, third trimester bleeding, malpresentation, fetal distress and meconium aspiration) and neonatal complications (eg narcotic withdrawal, microcephaly, neurobehavioural problems, increased neonatal mortality and increased risk of sudden infant death syndrome).
•In pregnancy, goals of treatment are to prevent withdrawal syndrome and toxic opioid levels, both of which pose sizeable risk to the fetus, as well as reducing other potentially harmful behaviours (eg risk of infection associated with injecting drugs) and increasing positive health behaviours (eg attendance for antenatal care).
•Methadone maintenance programmes have been widely used in pregnancy and have been shown to result in improved maternal and fetal health. Fewer data are available for buprenorphine, but it offers similar benefits to methadone. A Cochrane review failed to find significant differences between methadone and buprenorphine in pregnancy but research data were very limited.[13]
•Detoxification or withdrawal, if undertaken, is usually preferred in the second trimester due to increased risk of miscarriage in the first trimester and risk of premature labour and fetal stress in the third trimester.
•Advance planning as regards pain relief in labour and delivery in a unit with adequate obstetric and neonatal facilities.

Other management issues[2]

Sleep problems
•Sleep disorders are common amongst healthy pregnant women, with decreasing duration of sleep, increased rates of snoring and restless legs syndrome associated with progression of pregnancy. Over half of women in the third trimester report poor sleep quality.[14]
•Women with mental health problems who have sleep disorders should be advised about sleep hygiene measures (eg bedtime routines, avoiding caffeine, reduced activity before sleep).[15]
•Low-dose amitriptyline or chlorpromazine can be given if the problem is serious and chronic and does not respond to sleep hygiene measures.

Electroconvulsive therapy

ECT may be considered for pregnant women who have:
•Severe depression
•Severe mixed affective states or mania in the context of bipolar disorder
•Catatonia

It may be considered for pregnant women whose physical health or that of the fetus is at serious risk. Evidence is limited but the risks to mother and fetus appear low.[2]

Rapid tranquilisation

There may be occasions when a woman with disturbed/violent behaviour needs to be restrained and rapidly tranquilised (eg bipolar disorder, schizophrenia). The appropriate NICE guidance for the patient group needs to be followed but in addition:
•A restrained patient should not be secluded.
•Any restraint should be so adjusted as to not harm the fetus.
•An antipsychotic or benzodiazepine with a short half-life should be considered.
•Care should be planned with the involvement of an anaesthetist and paediatrician.

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Psychopharmacology in pregnancy[2][16]

The knee-jerk reaction to avoid all psychopharmacology in pregnancy is clearly wrong since untreated mental health problems may be substantially more risky than the medication itself. Any risk putatively associated with the use of psychoactive drugs should be considered in the context of the relatively high, age-related, background risk for congenital abnormalities and spontaneous abortion in the general population.[8] The risk/benefit ratio of medication needs careful consideration, ideally in advance of pregnancy. Stopping or switching medication may risk destabilisation or relapse.

Antidepressants
•Tricyclics – as a class, these carry the lowest known risk to the fetus, although they are more toxic in overdose than most other antidepressants (except lofepramine). There are some risks associated with individual members of the group (eg positive evidence of fetal risk with imipramine, increased risk of spontaneous abortion with trazodone).
•SSRIs – a warning was issued in 2005 advising that paroxetine should be avoided in the first trimester, as there were reports of congenital malformations, especially cardiac malformations, such as atrial and ventricular septal defects. NICE guidelines reflect this specific advice.[2] However, more recently, the Medicines and Healthcare products Regulatory Agency (MHRA) has advised that similar risks of congenital cardiac malformations are also found with fluoxetine (which was previously considered the safest SSRI) in pregnancy.[17] The absolute risk remains small. A class effect cannot be discounted.
•Monoamine oxidase inhibitors (MAOIs) – there is limited evidence of an increased risk of congenital malformation.
•Novel drugs – some drugs such as mirtazipine are too new to have extensive data about safety. Venlafaxine is not recommended in pregnancy by the manufacturers.
•Neonatal complications – pulmonary hypertension, jitteriness, crying and hypotonia have been reported in women taking antidepressants, SSRIs and tricyclics.

Anxiolytics and hypnotics
•Benzodiazepines – there is suggestion that exposure to benzodiazepines in the first trimester may be linked to congenital malformations (eg cleft palate). Exposure in later pregnancy can result in ‘floppy baby syndrome’ and withdrawal symptoms in the neonate. This class of drug should only be given for chronic severe symptoms, and prescribing limited to no longer than four weeks.
•’Z’ drugs (zopiclone, zolpidem and zaleplon) – there are very little data on the fetotoxicity of these drugs, although studies on zopiclone have not shown any association with major malformations compared with controls. There have been reports of hypothermia and respiratory depression when taken in the third trimester. In view of the lack of data, the British National Formulary (BNF) recommends avoiding this class of drugs in pregnancy.

Antipsychotics

The general consensus is that most antipsychotics are not associated with malformations.
•Clozapine: this should not be routinely used in pregnancy because of the theoretical risk of agranulocytosis in the fetus, and the woman should be switched to another drug.
•Olanzapine: this can cause weight gain and gestational diabetes, so risk factors such as existing weight, ethnicity and family history need to be taken into account.
•Depot antipsychotics: these should be avoided as there are insufficient safety data, and there have been reports of extrapyramidal effects in babies several months after maternal administration.
•Anticholinergic drugs: although frequently used as an adjunct to stave off extrapyramidal side-effects, they should be avoided in pregnancy. It is safer to alter the dosage and timings of the antipsychotic.

Mood stabilising drugs

The highest teratogenic risks are associated with the anticonvulsants (valproate > carbamazepine > lamotrigine). Lithium is also associated with teratogenicity, although the risk is lower than originally thought. Lowest risks appear to be associated with the antipsychotics, although experience of the use of the newer antipsychotics in pregnancy is very limited and warrants caution with these drugs.[8]
•Valproate: •This has a high teratogenic potential in the first 28 days of pregnancy.
•Long-term effects on cognitive development have been reported with exposure to valproate in pregnancy
•Women planning a pregnancy and requiring treatment for bipolar disorder should be switched to another antipsychotic.
•Women with an unplanned pregnancy should be switched as soon as possible.
•If there is no alternative to valproate, doses should be limited to a maximum of 1 gram per day, administered in divided doses and in the slow-release form, with 5 mg/day folic acid.

•Carbamazepine and lamotrigine – avoid in pregnancy because of the risk of neural tube defects and other malformations. A safer antipsychotic should be substituted.
•Lithium: •Lithium can cause cardiac defects in the fetus, particularly if taken in the first trimester.
•For a woman planning a pregnancy, lithium should be tailed off over four weeks (although this does not entirely remove the risk).
•If the patient requires further treatment, another antipsychotic should be introduced.
•If lithium is the only medication that controls symptoms and the patient is not going to breast-feed, it can be reintroduced in the second trimester.

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People with bulimia nervosa have episodes of binge eating. This is followed by deliberately making themselves sick (self-induced vomiting) or other measures to counteract the excessive food intake. Treatments include talking therapies, and sometimes medicines and self-help measures. Many people with bulimia get better with treatment.

What is bulimia nervosa?

Bulimia nervosa (often just called bulimia) is a condition where you think a lot about your body weight and shape. It affects your ability to have a ‘normal’ eating pattern. Bulimia is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia nervosa, you are most likely to be normal weight or even overweight.

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Eating Disorders – A Self Help Guide
Anorexia Nervosa
SSRI Antidepressants

How do I know if I have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder and you should see your doctor:
•Do you make yourself sick because you are uncomfortably full?
•Do you worry that you’ve lost control over how much you eat?
•Have you recently lost more than 6 kg (about one stone) in the past three months?
•Do you believe you’re fat when others think you’re thin?
•Would you say that food dominates your life?

Who gets bulimia nervosa?

Bulimia mainly affects women aged 16-40. It most commonly starts around the age of 19 years. It affects around 1 in 100 women in the UK. Bulimia sometimes develops in men and children. Women are ten times more likely than men to develop bulimia. However, bulimia is becoming more common in boys and men. Bulimia is more common than anorexia nervosa.

There may be some genetic factor, as the risk of developing bulimia in close relatives of people with bulimia is four times greater than in the general population.

What are the symptoms of bulimia nervosa?

Bingeing and purging are the main symptoms and are usually done in secret.
•Bingeing means that you have repeated episodes of eating large amounts of foods and/or drinks. For example, you may eat a whole large tub of ice cream or two packets of biscuits even if you are not hungry. You feel out of control and unable to stop eating. Binge eating is often done very quickly until you feel physically uncomfortable. This happens not just on one occasion, but regularly. Eating patterns typically become chaotic.
•Purging means that you try and counteract the ‘fattening’ effects of the food from the bingeing. Making yourself sick (self-induced vomiting) after a bout of bingeing is the most well-known, but not all people with bulimia do this. Other purging methods include taking lots of laxatives, extreme exercise, extreme dieting or even periods of complete starvation, taking ‘water’ tablets (diuretics) or taking other medicines such as amfetamines.

The reasons why you binge eat and then purge may not be easy to explain. Part of the problem may be due to a fear of getting fat, although it is often not just as simple as that. All sorts of emotions, feelings and attitudes may contribute. The physical act of bingeing and purging may be a way of dealing with your emotions in some way.

What are the physical problems caused by bulimia?

These are caused by the unusual eating habits and the methods used to purge the body of food (such as being sick (vomiting) or the excessive use of laxatives). Physical problems do not always develop. They are more likely if you binge and purge often. One or more of the following may develop:

Irregular periods

Many people have irregular periods as hormone levels can be affected by poor diet. Periods may even stop altogether or you may find that your periods have never started, especially if you started having eating problems when you were younger.

Chemical imbalances in the body

These are caused by either repeated vomiting or excess use of laxatives. For example, a low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to muscle spasms (tetany).

Bowel problems

These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.

Swelling of hands, feet and face

This is usually due to fluid disturbances in the body. The saliva glands in the face can sometimes swell due to the frequent vomiting.

Teeth problems

These can be caused by the acid from the stomach rotting away the enamel as a result of repeated vomiting.

Depression

It is fairly common to feel low when you have bulimia. Some people even become depressed, which can respond well to treatment. It is important to talk about any symptoms of depression you may have. Many people find they become more moody or irritable.

Psychological problems

These are very common and include feelings of guilt and disgust after bingeing and purging. Poor self-esteem, and mood swings, are common.

What causes bulimia nervosa?

The exact cause is not clear. Some people blame the media and the fashion industry which portray the idea that it is fashionable to be slim. This can put pressure on some people to try to be slim which can then lead to an eating disorder.

There may be some genetic factor to developing bulimia, which is triggered by stressful or traumatic life experiences. For example, some people with bulimia have had a childhood where there were frequent family problems with arguments and criticism at home. Some people with bulimia have been abused as a child.

Sometimes bulimia is also associated with some other psychological problem. (That is, the bulimia is sometimes just a part of a broader mental health problem.) For example, there is a higher than average rate of bulimia in people with anxiety disorders, obsessive-compulsive disorder, depression, post-traumatic stress disorder and some personality disorders.

A chemical called serotonin found in some parts of the brain is thought to have something to do with bulimia. In some way one or more of the above factors, or even other unknown factors, may lead to a low level of serotonin.

Are there any tests done for bulimia?

Although there is not an actual test to diagnose bulimia, your doctor may wish to undertake some blood tests. These are usually done to check your kidney function and potassium levels.

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Eating disorders – not just a teenage problem

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What are the treatments for bulimia nervosa?

The aim of treatment is to:
•Reduce risk of harm which can be caused by bulimia.
•Encourage healthy eating.
•Reduce other related symptoms and problems.
•Help people become both physically and mentally stronger.

Most people with bulimia who see their GP will be referred to a specialist eating disorder unit. Members of the team may include psychiatrists, psychologists, nurses, dietitians and other professionals.

The sort of treatments that may be offered include the following:

Help with eating

It is best if you have regular meals; even if you only eat small meals. It is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other people) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary in order to write down all the food that you eat.

Psychological (‘talking’) treatments

Cognitive behavioural therapy (CBT) is the most commonly used psychological treatment for bulimia. It helps you to look at the reasons why you developed bulimia, aims to change any false beliefs that you have about your weight and body, and it helps to show you how to deal with emotional issues. Talking treatments take time and usually require regular sessions over several months.

However, CBT does not suit everyone. About a third of people drop out before finishing the course. Other forms of psychological therapies, either in groups, on an individual basis or using computer-based packages may also be used.

Medication

A medicine may be advised by your doctor. The most commonly used medicines are selective serotonin reuptake inhibitor (SSRI) antidepressants. These are used to treat depression but, in higher doses, one called fluoxetine can reduce the urge for bingeing or purging. These are not usually recommended if you are younger than 18 years old.

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Bulimia nervosa
Self-help measures

There are a number of self-help books and manuals available. These provide strategies in how to cope with, and overcome, bulimia. Some people find these very helpful and prefer them to ‘formal’ treatment. It is certainly worth trying a self-help manual if there is a waiting list or difficulty in getting psychological treatment.

Treatment of any physical or teeth problems that may occur

This may include taking potassium supplements, dental care and help with cutting down use of laxatives.

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What is the outlook (prognosis)?

Bulimia is the sort of condition that is difficult to cure fully ‘once and for all’. Many people improve with treatment, but bad spells (relapses) may recur from time to time in some cases. Many people find they still have issues with food, even after treatment, but they are more in control and can lead happier, more fulfilled lives.

Studies suggest that 10 years after a diagnosis of bulimia about 5 in 10 people are well, about 2 in 10 people still have bulimia, and about 3 in 10 people are somewhere in the middle. However, the recent study about CBT treatment (see the end of the leaflet) suggests that with good-quality CBT, the outlook is probably even better than these ‘overall’ figures. It is very unusual to die from bulimia.

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