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Bulimia nervosa
OVERVIEW: 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
Predominant sex: Female > Male
SIGNS AND SYMPTOMS: • 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
CAUSES: 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, obesity, depression
DIAGNOSIS 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
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
SPECIAL TESTS: • ECG
• Gastric motility
• Thyroid, liver, renal function
• Drug screen
IMAGING: Not indicated
DIAGNOSTIC PROCEDURES: Psychological screening: Eating Attitudes Test, BULIT, SCANS, EDI
TREATMENT 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.
SURGICAL MEASURES: N/A
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
• Information on nutrition, metabolic balance
• Tools for self monitoring when appropriate
MEDICATIONS DRUG(S) OF CHOICE: • SSRIs - fluoxetine (Prozac) 10-80 mg or fluvoxamine (Luvox) 50-300 mg/day are effective in reducing symptoms with relatively few side effects. High dose treatment often needed.
• TCAs - imipramine (Tofranil), 10 mg, gradual increase to 250 mg if needed (monitor with ECG) (maximum dosage for adolescents 100 mg) or desipramine, (Norpramin) 25 mg/day, increasing gradually to 150 mg/day if needed (monitor with ECG). Improvement is not necessarily related to blood level.
• MAO inhibitors - phenelzine (Nardil) 60-90 mg/day. Patients with atypical depression may respond to MAO inhibitors.
• When patients do not respond to a drug in one class (or experiences side effects), try a drug of a different class. 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
ALTERNATIVE DRUGS: • 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
• Psyllium (Metamucil) preparations 1 tbsp hs with glass of water, can prevent constipation during laxative withdrawal
• Cisapride (Propulsid), 10-20 mg before each meal and at bedtime for post-prandial abdominal discomfort (not generally recommended)
FOLLOW UP 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
EXPECTED COURSE AND 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
SYNONYMS: N/A
ICD-9-CM: 307.51 Bulimia (overeating of nonorganic origin)
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Hyperkalemia
Laxative abuse
Salivary gland tumors
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