Bulimia Nervosa

1. Epidemiology
   1. Onset in adolescence or early adulthood
   2. Affects women much more than men by ratio of 10-20:1
2. Symptoms
   1. Bloating or abdominal fullness sensation
   2. Gastroesophageal Reflux disease
   3. Abdominal Pain
   4. Pharyngitis
   5. Severe Constipation (withdrawal from Laxatives)
3. Signs
   1. Disordered eating and distorted body image
      1. See DSM IV Diagnosis below
   2. Patients are most often of normal weight
      1. Contrast with under-weight in Anorexia Nervosa
   3. Poor impulse control
   4. Physical signs of Bulimia
      1. Callused knuckles
      2. Dental Erosions
      3. Salivary Gland hypertrophy
      4. Mallory-Weiss Tear
4. Evaluation Tools
   1. See SCOFF Questionnaire
5. Diagnosis: DSM IV
   1. Major Criteria
      1. Recurrent Binge Eating
         1. Eating more than most people eat per time period
         2. Perceived lack of control during eating episode
      2. Compensatory behaviors to prevent weight gain
         1. Purging
            1. Self-induced Vomiting
            2. Medication misuse (see purging behavior above)
               1. Diet pills
               2. Laxatives or enemas
               3. Diuretics
         2. Other inappropriate weight loss control
            1. Fasting
            2. Excessive Exercise
      3. Binging and weight loss twice weekly over 3 months
      4. Overconcern with body shape and weight
      5. Episodes not limited to Anorexia Nervosa episodes
   2. Subtypes
      1. Purging Type
         1. Regular, ongoing purging behaviors (see above)
      2. Non-purging type
         1. No purging behaviors
         2. Weight controlled with fasting, excessive Exercise
6. Associated Conditions
   1. Female Athlete Triad
   2. Oligomenorrhea (50% of cases)
      1. No associated bone loss (contrast with anorexia)
      2. Weight bearing Exercise protective of bone in Bulimia
   3. Psychiatric illness
      1. See Anorexia
      2. Personality Disorder (confers worse prognosis)
         1. Cluster B - dramatic, erratic
         2. Borderline Personality Disorder
         3. Narcissistic Personality Disorder
         4. Antisocial Personality Disorder
      3. Self deprecation and low self esteem
      4. Major Depression with suicidal ruminations
      5. Anxiety Disorder
   4. Risk-taking behaviors
      1. Substance Abuse
      2. Unprotected sexual activity
      3. Self mutilation
7. Differential Diagnosis
   1. See Anorexia
8. Labs
   1. Chemistry panel
      1. Hypochloremic Metabolic Alkalosis
      2. Hypokalemia
   2. Serum Amylase increased
9. Diagnostics: Electrocardiogram
   1. Same as in anorexia
10. Management: General
    1. Hypokalemia management if present
    2. Prevention of secondary complications
       1. Fluoridated Mouthwash and Toothpaste
       2. Sour candy to decrease Salivary Gland swelling
       3. Antacid medications for Reflux Esophagitis
11. Management: Psychiatric
    1. Cognitive behavior therapy
       1. Cognitive behavior therapy is first line management
       2. Effective in only 40 to 50% of bulimic patients
       3. Indications to consider alternative therapy
          1. Purging not reduced 70% by sixth session
    2. Antidepressant agents are effective adjuncts to therapy
       1. Effexor
       2. Serzone
       3. Fluoxetine and other Selective Serotonin Reuptake Inhibitors (SSRI)
       4. Avoid Wellbutrin (due to Seizure risk)
12. Management: Oligomenorrhea
    1. History and physical examination
       1. Consistent with Anovulation
    2. Laboratory evaluation for significant oligomenorrhea
       1. Urine Pregnancy Test
       2. Luteinizing hormone (LH)
       3. Follicle Stimulating Hormone (FSH)
       4. Thyroid Stimulating Hormone (TSH)
       5. Prolactin
       6. Total Testosterone and Free Testosterone
       7. Consider Serum Dehydroepiandrosterone sulfate level
          1. Indicated for signs of androgenization
    3. Suspected Unopposed Estrogen management
       1. Patient characteristics
          1. Normal weight patient
          2. Anovulation
          3. Elevated androgen levels
          4. Withdrawal bleed after Provera 10 mg x7 days trial
       2. Protocol for Endometrial Cancer prevention
          1. Provera 10 mg qd for 7 days repeated q3 months or
          2. Oral Contraceptive cycling
13. References
    1. (1994) DSM IV, APA, p. 544-5
    2. Agras (2000) Am J Psychiatry 157:1302-8
    3. McGilley (1998) Am Fam Physician, 57(11): 2743-50
    4. Mehler (2003) N Engl J Med 349:875-81
    5. Seidenfeld (2001) Am Fam Physician 64(3):445-50
    6. Sundgot-Borgen (1998) J Clin Endocrinol Metab 83:3144-9
    7. Walsh (2004) Am J Psychiatry 161:556-61
    8. Yanovski (1991) Am Fam Physician, 44(4): 1231-38
14. Resources
    1. Jackson (1991) Dieting: Dry Drunk- Dieting Recovery