Bulimia Nervosa

Aka: Bulimia Nervosa, Bulimia

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II. Epidemiology

  1. Onset in adolescence or early adulthood
  2. Prevalence: 4-6 per 200 females in U.S. (much more common than Anorexia)
  3. Affects women much more than men by ratio of 10-20:1

III. Risk Factors

  1. Similar personality traits as with Anorexia Nervosa (common to other Eating Disorders)
    1. Perfectionist, high achiever, who values success and external rewards
    2. Food and appearance regulation is under their control
  2. Sexual Assault or sexual abuse
    1. Increases Bulimia risk

IV. Symptoms

  1. Bloating or abdominal fullness Sensation
  2. Gastroesophageal Reflux disease
  3. Abdominal Pain
  4. Pharyngitis
  5. Severe Constipation (withdrawal from Laxatives)
  6. Behaviors to control weight
    1. Binge Eating
    2. Purging (induced Vomiting, Laxative use, Diuretics)
    3. Establishes elaborate schedules to allow for Binge Eating, purging and frequent bathroom use
    4. Excessive Exercise

V. 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
    2. Weight in Bulimia tends to fluctuate
  3. Poor impulse control
  4. Physical signs of Bulimia
    1. Callused knuckles (Russell Sign)
    2. Dental enamel erosions and Gingivitis
    3. Salivary Gland hypertrophy (esp. Parotid Gland)
    4. Mallory-Weiss Tear (from forceful Vomiting)
    5. Edema

VI. Evaluation Tools

  1. See SCOFF Questionnaire

VII. Diagnosis: DSM V

  1. Major Criteria
    1. Recurrent Binge Eating
      1. Eating more than most people eat per time period (e.g. 2 hours)
      2. Perceived lack of control during eating episode (unable to stop eating)
    2. Recurrent 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 on average at least 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
  3. Remission Criteria
    1. Partial Remission
      1. Previously met full major criteria for Bulimia
      2. Now meets some, but not all Bulimia criteria for a sustained period of time
    2. Full Remission
      1. Previously met full major criteria for Bulimia
      2. Now meets none of the major criteria for Bulimia for a sustained period of time
  4. Severity (for adults, use BMI percentiles for children and adolescents)
    1. Mild
      1. An average of 1-3 episodes of inappropriate compensatory behaviors weekly
    2. Moderate
      1. An average of 4-7 episodes of inappropriate compensatory behaviors weekly
    3. Severe
      1. An average of 8-13 episodes of inappropriate compensatory behaviors weekly
    4. Extreme
      1. An average of 14 or more episodes of inappropriate compensatory behaviors weekly
  5. References
    1. (2013) DSM V, APA, Washington

VIII. 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

IX. Differential Diagnosis

  1. See Anorexia

X. Labs

  1. Complete Blood Count
    1. Leukopenia
  2. Comprehensive Metabolic Panel (changes related to purging)
    1. Hypochloremic Metabolic Alkalosis
    2. Hypokalemia
  3. Serum Amylase
    1. May be increased with induced Vomiting
    2. Serum Lipase is often normal
    3. Humphries (1987) Ann Intern Med 106(1):50-2 +PMID:2431640 [PubMed]
  4. Serum Phosphorus
  5. Serum Magnesium
  6. Thyroid Stimulating Hormone
  7. Urinalysis
    1. Increased Urine Specific Gravity
    2. Increased Urine Ketones
    3. Decreased Urine pH

XI. Diagnostics: Electrocardiogram

  1. Same as in Anorexia

XII. Management: Inpatient Indications

  1. Suicidal Ideation with plan
  2. Intractable Vomiting
  3. Hematemesis
  4. Mallory-Weiss Tear (Esophageal Tear)
  5. Syncope
  6. Prolonged QTc or Cardiac Arrhythmia
  7. Serum Potassium <3.2 mg/dl
  8. Serum Chloride <88 mg/dl
  9. Hypothermia
  10. Failed outpatient management
  11. References
    1. Campbell (2014) Pediatrics 134(3): 582-92 [PubMed]

XIII. 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

XIV. 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. Venlafaxine (Effexor)
    2. Fluoxetine
      1. Titrate to 60 mg orally daily over 2 to 3 weeks
    3. Other Selective Serotonin Reuptake Inhibitors (SSRI)
    4. Avoid Wellbutrin (Seizure risk)
  3. Other medications
    1. Topiramate
      1. May decrease Binge Eating, but also risks Cognitive Impairment while on the medication

XV. 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

XVI. Prognosis

  1. Remission rate with treatment: 80%
  2. Relapse rate: 20%
  3. All-cause mortality relative ratio: 1.6-1.9

XVII. Resources

  1. Jackson (1991) Dieting: Dry Drunk- Dieting Recovery

XVIII. References

  1. (1994) DSM IV, APA, p. 544-5
  2. Renbarger and Pearson (2021) Crit Dec Emerg Med 35(8): 17-23
  3. Agras (2000) Am J Psychiatry 157:1302-8 [PubMed]
  4. Harrington (2014) Am Fam Physician 91(1): 46-52 [PubMed]
  5. Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]
  6. McGilley (1998) Am Fam Physician, 57(11): 2743-50 [PubMed]
  7. Mehler (2003) N Engl J Med 349:875-81 [PubMed]
  8. Seidenfeld (2001) Am Fam Physician 64(3):445-50 [PubMed]
  9. Sundgot-Borgen (1998) J Clin Endocrinol Metab 83:3144-9 [PubMed]
  10. Walsh (2004) Am J Psychiatry 161:556-61 [PubMed]
  11. Yanovski (1991) Am Fam Physician, 44(4): 1231-38 [PubMed]

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