tend to have more bulimic symptoms than those women who do not. this further demonstrates the impact of media on the likelihood of developing the disorder. individuals first accept and "buy into" the ideals, and then attempt to transform themselves in order to reflect the societal ideals of attractiveness. j. kevin thompson and eric stice claim that family, peers, and most evidently media reinforce the thin ideal, which may lead to an individual accepting and "buying into" the thin ideal. in turn, thompson and stice assert that if the thin ideal is accepted, one could begin to feel uncomfortable with their body shape or size since it may not necessarily reflect the thin ideal set out by society. thus, people feeling uncomfortable with their bodies may result in body dissatisfaction and may develop a certain drive for thinness. consequently, body dissatisfaction coupled with a drive for thinness is thought to promote dieting and negative effects, which could eventually lead to bulimic symptoms such as purging or bingeing. binges lead to self-disgust which causes purging to prevent weight gain. a study dedicated to investigating the thin ideal internalization as a factor of bulimia nervosa is thompson's and stice's research. their study aimed to investigate how and to what degree media affects the thin ideal internalization. thompson and stice used randomized experiments (more specifically programs) dedicated to teaching young women how to be more critical when it comes to media, to reduce thin-ideal internalization. the results showed that by creating more awareness of the media's control of the societal ideal of attractiveness, the thin ideal internalization significantly dropped. in other words, less thin ideal images portrayed by the media resulted in less thin-ideal internalization. therefore, thompson and stice concluded that media greatly affected the thin ideal internalization. papies showed that it is not the thin ideal itself, but rather the self-association with other persons of a certain weight that decide how someone with bulimia nervosa feels. people that associate themselves with thin models get in a positive attitude when they see thin models and people that associate with overweight get in a negative attitude when they see thin models. moreover, it can be taught to associate with thinner people. diagnosis the onset of bulimia nervosa is often during adolescence, between 13 and 20 years of age, and many cases have previously experienced obesity, with many relapsing in adulthood into episodic bingeing and purging even after initially successful treatment and remission. a lifetime prevalence of 0.5 percent and 0.9 percent for adults and adolescents, respectively, is estimated among the united states population. bulimia nervosa may affect up to 1% of young women and, after 10 years of diagnosis, half will recover fully, a third will recover partially, and 10–20% will still have symptoms. adolescents with bulimia nervosa are more likely to have self-imposed perfectionism and compulsivity issues in eating compared to their peers. this means that the high expectations and unrealistic goals that these individuals set for themselves are internally motivated rather than by social views or expectations. criteria bulimia nervosa can be difficult to detect, compared to anorexia nervosa, because bulimics tend to be of average or slightly above average weight. many bulimics may also engage in significantly disordered eating and exercise patterns without meeting the full diagnostic criteria for bulimia nervosa. recently, the diagnostic and statistical manual of mental disorders was revised, which resulted in the loosening of criteria regarding the diagnoses of bulimia nervosa and anorexia nervosa. the diagnostic criteria utilized by the dsm-5 includes repetitive episodes of binge eating (a discrete episode of overeating during which the individual feels out of control of consumption) compensated for by excessive or inappropriate measures taken to avoid gaining weight. the diagnosis also requires the episodes of compensatory behaviors and binge eating to happen a minimum of once a week for a consistent time period of 3 months. the diagnosis is made only when the behavior is not a part of the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on physical mass or appearance. purging often is a common characteristic of a more severe case of bulimia nervosa. treatment there are two main types of treatment given to those with bulimia nervosa; psychopharmacological and psychosocial treatments. psychotherapy cognitive behavioral therapy is the primary treatment for bulimia. antidepressants of the selective serotonin reuptake inhibitor (ssri) or tricyclic antidepressant classes may have a modest benefit. while outcomes with bulimia are typically better than in those with anorexia, the risk of death among those affected is higher than that of the general population. at 10 years after receiving treatment about 50% of people are fully recovered. cognitive behavioral therapy (cbt), which involves teaching a person to challenge automatic thoughts and engage in behavioral experiments (for example, in session eating of "forbidden foods") has a small amount of evidence supporting its use. by using cbt people record how much food they eat and periods of vomiting with the purpose of identifying and avoiding emotional fluctuations that bring on episodes of bulimia on a regular basis. barker (2003) states that research has found 40–60% of people using cognitive behaviour therapy to become symptom free. he states in order for the therapy to work, all parties must work together to discuss, record and develop coping strategies. barker (2003) claims by making people aware of their actions they will think of alternatives. people undergoing cbt who exhibit early behavioral changes are most likely to achieve the best treatment outcomes in the long run. researchers have also reported some positive outcomes for interpersonal psychotherapy and dialectical behavior therapy. maudsley family therapy, developed at the maudsley hospital in london for the treatment of anorexia, has been shown promising results in bulimia. the use of cbt has been shown to be quite effective for treating bulimia nervosa (bn) in adults, but little research has been done on effective treatments of bn for adolescents. although cbt is seen as more cost-efficient and helps individuals with bn in self-guided care, family based treatment (fbt) might be more helpful to younger adolescents who need more support and guidance from their families. adolescents are at the stage where their brains are still quite malleable and developing gradually. therefore, young adolescents with bn are less likely to realize the detrimental consequences of becoming bulimic and have less motivation to change, which is why fbt would be useful to have families intervene and support the teens. working with bn patients and their families in fbt can empower the families by having them involved in their adolescent's food choices and behaviors, taking more control of the situation in the beginning and gradually letting the adolescent become more autonomous when they have learned healthier eating habits. medication antidepressants of the selective serotonin reuptake inhibitors (ssri) class may have a modest benefit. this includes fluoxetine, also known as prozac, which is fda approved, for the treatment of bulimia, other antidepressants such as sertraline may also be effective against bulimia. topiramate may also be useful but has greater side effects. compared to placebo, the use of a single antidepressant has been shown to be effective. combining medication with counseling can improve outcomes in some circumstances. some positive outcomes of treatments can include: abstinence from binge eating, a decrease in obsessive behaviors to lose weight and in shape preoccupation, less severe psychiatric symptoms, a desire to counter the effects of binge eating, as well as an improvement in social functioning and reduced relapse rates. alternative medicine some researchers have also claimed positive outcomes in hypnotherapy. the first use of hypnotherapy in bulimic patients was in 1981. when it comes to hypnotherapy, bulimic patients are easier to hypnotize than anorexia nervosa patients. in bulimic patients, hypnotherapy focuses on learning self-control when it comes to binging and vomiting, strengthening stimulus control techniques, enhancing ones ego, improving weight control, and helping overweight patients see their body differently (have a different image). risk factors being female and having bulimia nervosa takes a toll on mental health. women frequently reported an onset of anxiety at the same time of the onset of bulimia nervosa. another concern with eating disorders is developing a coexisting substance use disorder. epidemiology deaths due to eating disorders per million persons in 2012 0-0 1-1 2-2 3-3 4–25 there is little data on the percentage of people with bulimia in general populations. most studies conducted thus far have been on convenience samples from hospital patients, high school or university students. these have yielded a wide range of results: between 0.1% and 1.4% of males, and between 0.3% and 9.4% of females. studies on time trends in the prevalence of bulimia nervosa have also yielded inconsistent results. according to gelder, mayou and geddes (2005) bulimia nervosa is prevalent between 1 and 2 percent of women aged 15–40 years. bulimia nervosa occurs more frequently in developed countries and in cities, with one study finding that bulimia is five times more prevalent in cities than in rural areas. there is a perception that bulimia is most prevalent amongst girls from middle-class families; however, in a 2009 study girls from families in the lowest income bracket studied were 153 percent more likely to be bulimic than girls from the highest income bracket. there are higher rates of eating disorders in groups involved in activities which idealize a slim physique, such as dance, gymnastics, modeling, cheerleading, running, acting, swimming, diving, rowing and figure skating. bulimia is thought to be more prevalent among caucasians; however, a more recent study showed that african-american teenage girls were 50 percent more likely than caucasian girls to exhibit bulimic behavior, including both binging and purging. country year sample size and type % affected portugal20062,028 high school students0.3% female brazil20041,807 students (ages 7–19)0.8% male1.3% female spain20042,509 female adolescents (ages 13–22)1.4% female hungary2003580 budapest residents0.4% male3.6% female australia19984,200 high school students0.3% combined united states19961,152 college students0.2% male1.3% female norway199519,067 psychiatric patients0.7% male7.3% female canada19958,116 (random sample)0.1% male1.1% female japan19952,597 high school students0.7% male1.9% female united states1992799 college students0.4% male5.1% female history etymology the term bulimia comes from greek βουλιμία boulīmia, "ravenous hunger", a compound of βοῦς bous, "ox" and λιμός, līmos, "hunger". literally, the scientific name of the disorder, bulimia nervosa, translates to "nervous ravenous hunger". before the 20th century although diagnostic criteria for bulimia nervosa did not appear until 1979, evidence suggests that binging and purging were popular in certain ancient cultures. the first documented account of behavior resembling bulimia nervosa was recorded in xenophon's anabasis around 370 b.c, in which greek soldiers purged themselves in the mountains of asia minor. it is unclear whether this purging was preceded by binging. in ancient egypt, physicians recommended purging once a month for three days to preserve health. this practice stemmed from the belief that human diseases were caused by the food itself. in ancient rome, elite society members would vomit to "make room" in their stomachs for more food at all-day banquets. emperors claudius and vitellius both were gluttonous and obese, and they often resorted to habitual purging. historical records also suggest that some saints who developed anorexia (as a result of a life of asceticism) may also have displayed bulimic behaviors. saint mary magdalen de pazzi (1566–1607) and saint veronica giuliani (1660–1727) were both observed binge eating—giving in, as they believed, to the temptations of the devil. saint catherine of siena (1347–1380) is known to have supplemented her strict abstinence from food by purging as reparation for her sins. catherine died from starvation at age thirty-three. while the psychological disorder "bulimia nervosa" is relatively new, the word "bulimia", signifying overeating, has been present for centuries. the babylon talmud referenced practices of "bulimia", yet scholars believe that this simply referred to overeating without the purging or the psychological implications bulimia nervosa. in fact, a search for evidence of bulimia nervosa from the 17th to late 19th century revealed that only a quarter of the overeating cases they examined actually vomited after the binges. there was no evidence of deliberate vomiting or an attempt to control weight. 20th century globally, bulimia was estimated to affect 3.6 million people in 2015. about 1% of young women have bulimia at a given point in time and about 2% to 3% of women have the condition at some point in their lives. the condition