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Bulimia nervosa

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Description of Medical Condition

Classified in purging and non-purging subtypes. Purging often by self-induced vomiting, laxatives, diuretics. Non-purging type consists of — binges followed by sharply restricted diet and/or vigorous exercise.

System(s) affected: Endocrine/Metabolic, Nervous, Gastrointestinal, Cardiovascular

Genetics: Genetic component

Incidence/Prevalence in USA: Approximately 2% of females; higher among university women. True incidence is not known as this is a secretive disease.

Predominant age: Adolescents and young adults; can occur at any age

Predominant sex: Female > Male (5:1)

Medical Symptoms and Signs of Disease

• Patients may switch back and forth between purging and non-purging bulimia

• Onset may be stress related

• May be average weight or even somewhat obese; most are slightly below average weight

• Frequent fluctuations in weight

• Deny that there is a problem

• Gobble high calorie foods during binge

• Preoccupation with weight control

• Food collection and hoarding

• Diet pill, diuretic, laxative, ipecac and thyroid medication abuse

• Prefers vigorous exercise, especially running, aerobics

• Diabetic patients often withhold insulin

• Depressed mood and self-depreciation following the binges

• Relief and increased ability to concentrate following the purges

• Vomiting (may be effortless)

• Abdominal pain

• Parotid swelling

• Eroded teeth

• Scarred hands or abrasions on back of hands

• Cardiomyopathy and muscle weakness due to ipecac abuse
bulimia_nervosa

What Causes Disease?

• Thought to be largely emotional

• Moderate genetic influence

Risk Factors

• Depression, obsessionality, impulsivity

• Low self-esteem

• Achievement pressure; high self-expectations; social anxiety

• Acceptance of the culturally condoned ideal of slimness

• Ambivalence about dependence/independence

• Stress due to multiple responsibilities, tight schedules, competition

• Weight dissatisfaction; perceived overweight

• Environment that stresses thinness or physical fitness (eg, armed forces)

• Family history of substance abuse, eating disorder, obesity, depression

• Poor impulse control, ETOH misuse

• Difficulty resolving conflict, expressing negative emotions

Diagnosis of Disease

Differential Diagnosis

• Major depressive disorder

• Anorexia, binge eating/purging type

• Psychogenic vomiting

• Hypothalamic brain tumor

• Epileptic equivalent seizures

• Kluver-Bucy-like syndromes

• Kleine-Levin syndrome

• Body dysmorphic disorder

Laboratory

• All results may be within normal limits

• Elevated BUN

• Hypokalemia, hypochloremia

• Hypomagnesemia

• Elevated basal serum prolactin

• Mild elevation serum amylase

• Positive dexamethasone suppression test

• Low CD4/CD8 ratio

• Reduced serotonin activity

• Blunted prolactin response to serotonin agonists

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

• Eroded tooth enamel

• Esophagitis, Mallory-Weiss tears

• Asymptomatic, non-inflammatory parotid enlargement

• Gastric dilatation

• Infarction and perforation of the stomach

• Acute pancreatitis

• Spontaneous pneumomediastinum

Special Tests

• ECG

• Gastric motility

• Thyroid, liver, renal function

• Drug screen

Imaging

Not indicated

Diagnostic Procedures

Psychologi cal screening: Eating Attitudes Test, BULIT, SCANS, EDI

Treatment (Medical Therapy)

Appropriate Health Care

• Most patients can be treated as outpatients

• Hospitalize if patient is suicidal; if there is lab or ECG evidence of marked electrolyte imbalance; marked dehydration; or if there has been no response to outpatient therapy

General Measures

• Inpatient:

– If possible, admit to eating disorders unit or unit with structured eating disorders program

– Supervised meals and bathroom privileges

– No access to the bathroom for 2 hours after meals

– Monitor weight and physical activity

– Assess psychological state and nutritional status

– Identify precipitants to bingeing

– Develop alternatives to purging

– Monitor electrolytes

– Focal individual and cognitive behavioral therapy.

Frequent visits by physician.

– Gradually shift control to patient as she demonstrates responsibility

• Outpatient:

– Build trust, treatment alliance

– Assess psychological state and nutritional status

– Involve patient in establishing target goals

– Use self-monitoring techniques such as food diary

– Identify prodromal states, precipitants

– Address ruminations about calories, weight, purging

– Focus on overall well-being, developing gratifying relationships

– Challenge fear of loss of control

– Cognitive-behavioral therapy and interpersonal therapy

– Family therapy for adolescents

– Nutritional education, relaxation techniques, couples therapy, self-help group may also be helpful.

Activity

• Monitor excess activity

• Stress importance of playful, pleasurable activities

Diet

• Goal is a balanced diet with adequate calories and a normal eating pattern

• Reintroduce feared foods

Patient Education

• Seriousness and consequences of bulimic behavior including cognitive impairment

• Information on nutrition, metabolic balance

• Tools for self monitoring when appropriate

Medications (Drugs, Medicines)

Drug(s) of Choice

• SSRIs — fluoxetine (Prozac) 10-80 mg orfluvoxamine (Luvox) 50-300 mg/day are effective in reducing symptoms with relatively few side effects. High dose treatment often needed.

• MAO inhibitors — phenelzine (Nardil) 60-90 mg/day. Patients with atypical depression may respond to MAO inhibitors and not SSRIs.

• Augment with buspirone (BuSpar) if desired. To prevent relapse, maintain antidepressant medication at full therapeutic dose for at least one year.

• Note: Dishonesty and noncompliance are common

Contraindications: Refer to manufacturer’s literature

Precautions:

• Serious toxicity following overdose is common

• Patients often vomit medications

Significant possible interactions:

• Lithium and tricyclic medication can be lethal when administered to hypokalemic patients

• SSRIs may increase tricyclic levels

• Because of danger of food related hypertensive crises, use irreversible MAO inhibitors only with fully cooperative patients

• To avoid the serotonin syndrome, allow 5 weeks between discontinuing fluoxetine and beginning MAO inhibitor

• Avoid co-administration of bupropion (Wellbutrin. Zyban) as this may precipitate seizures

Alternative Drugs

• Inositol (a nutrient) 10-18 g/day; controlled trial indicated effects comparable to SSRIs

• Domperidone (Motilium) 10 mg before meals relieves bloating, abdominal pain; favorable safety profile

• Sibutramine (Meridia) 13 mg in AM is of theorized interest; research is lacking

• If there is an underlying bipolar disorder, patients may benefit from lithium (Eskalith), 300 mg bid, increase gradually to therapeutic blood level of 0.6-1.2 mEq/L (0.6-1.2 mmol/L)

• Ondansetron (Zofran) 4-8 mg tid between meals can help prevent vomiting

• Reboxetine (Vestra, Edronax), an SNRI, seems effective in treating the underlying psychopathology

• Psyllium (Metamucil) preparations 1 tbsp hs with glass of water, can prevent constipation during laxative withdrawal

Patient Monitoring

• Binge-purge activity

• Level of exercise activity

• Self-esteem, comfort with body and self

• Ruminations and depression

• Repeat any abnormal lab values weekly or monthly until stable

Prevention / Avoidance

• Encourage rational attitude about weight

• Moderate overly high self-expectations

• Enhance self-esteem

• Diminish stress

Possible Complications

• Suicide

• Drug and alcohol abuse

• Potassium depletion; cardiac arrhythmia; cardiac arrest

• Maternal and fetal problems if pregnant

Expected Course / Prognosis

• Highly variable, tends to wax and wane

• May spontaneously remit

• Most patients continue to binge/purge, but do so less often

• Patients who do not establish trust likely to drop out of therapy, be lost to follow-up

• Those who stay in therapy tend to improve

• Patients with personality disorders have a generally poor prognosis

• 30-50% relapse rate per year for several years

• Impulsive patients may engage in stealing, suicide gestures, substance abuse, promiscuity

Miscellaneous

Associated Conditions

• Major depression and dysthymia

• Bipolar disorder

• Obsessive-compulsive disorder

• Social phobia and other anxiety disorders

• Schizophrenic disorder

• Substance abuse disorder

• Borderline personality disorder

• Compulsive shoplifting (kleptomania)

Age-Related Factors

Pediatric: N/A

Geriatric: N/A

Others: Less frequently diagnosed in men or in older women

Pregnancy

• Poor nutritional status may affect fetus

• Binge-purge may increase or decrease during pregnancy

International Classification of Diseases

307.51 Bulimia

See Also

Hyperkalemia Laxative abuse Salivary gland tumors

Other Notes

• Anorexic patients may deal with the frustration of chronic food deprivation by converting to bulimia

• High risk

– Ballet dancers, models, cheerleaders

– Athletes, especially runners, gymnasts, weight lifters, body builders, jockeys, divers, wrestlers, figure skaters, field hockey players

• Sub-clinical eating disorders are common in university populations

• Sexual abuse is not causally related to bulimia

• Chronic, extreme hypokalemia can occur without physical symptoms

Abbreviations

MAO = monoamine oxidase

SRI = serotonin reuptake inhibitors

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