Bulimia nervosa

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

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

1. High risk

– Ballet dancers, models, cheerleaders

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

2. Sub-clinical eating disorders are common in university populations

3. Sexual abuse is not causally related to bulimia

4. Chronic, extreme hypokalemia can occur without physical symptoms

Abbreviations

MAO = monoamine oxidase

SRI = serotonin reuptake inhibitors