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Bulimia Nervosa
Aka: Bulimia Nervosa, Bulimia
- See Also
- Eating Disorder
- Anorexia Nervosa
- Avoidant-Restrictive Food Intake Disorder (ARFID)
- Epidemiology
- Onset in adolescence or early adulthood
- Prevalence: 4-6 per 200 females in U.S. (much more common than Anorexia)
- Affects women much more than men by ratio of 10-20:1
- Risk Factors
- Similar personality traits as with Anorexia Nervosa (common to other Eating Disorders)
- Perfectionist, high achiever, who values success and external rewards
- Food and appearance regulation is under their control
- Sexual Assault or sexual abuse
- Increases Bulimia risk
- Symptoms
- Bloating or abdominal fullness sensation
- Gastroesophageal Reflux disease
- Abdominal Pain
- Pharyngitis
- Severe Constipation (withdrawal from Laxatives)
- Behaviors to control weight
- Binge Eating
- Purging (induced Vomiting, Laxative use, Diuretics)
- Establishes elaborate schedules to allow for Binge Eating, purging and frequent bathroom use
- Excessive Exercise
- Signs
- Disordered eating and distorted body image
- See DSM IV Diagnosis below
- Patients are most often of normal weight
- Contrast with under-weight in Anorexia Nervosa
- Weight in Bulimia tends to fluctuate
- Poor impulse control
- Physical signs of Bulimia
- Callused knuckles (Russell Sign)
- Dental enamel erosions and Gingivitis
- Salivary Gland hypertrophy (esp. Parotid Gland)
- Mallory-Weiss Tear (from forceful Vomiting)
- Edema
- Evaluation Tools
- See SCOFF Questionnaire
- Diagnosis: DSM V
- Major Criteria
- Recurrent Binge Eating
- Eating more than most people eat per time period (e.g. 2 hours)
- Perceived lack of control during eating episode (unable to stop eating)
- Recurrent compensatory behaviors to prevent weight gain
- Purging
- Self-induced Vomiting
- Medication misuse (see purging behavior above)
- Diet pills
- Laxatives or enemas
- Diuretics
- Other inappropriate weight loss control
- Fasting
- Excessive Exercise
- Binging and weight loss on average at least weekly over 3 months
- Overconcern with body shape and weight
- Episodes not limited to Anorexia Nervosa episodes
- Subtypes
- Purging Type
- Regular, ongoing purging behaviors (see above)
- Non-purging type
- No purging behaviors
- Weight controlled with Fasting, excessive Exercise
- Remission Criteria
- Partial Remission
- Previously met full major criteria for Bulimia
- Now meets some, but not all Bulimia criteria for a sustained period of time
- Full Remission
- Previously met full major criteria for Bulimia
- Now meets none of the major criteria for Bulimia for a sustained period of time
- Severity (for adults, use BMI percentiles for children and adolescents)
- Mild
- An average of 1-3 episodes of inappropriate compensatory behaviors weekly
- Moderate
- An average of 4-7 episodes of inappropriate compensatory behaviors weekly
- Severe
- An average of 8-13 episodes of inappropriate compensatory behaviors weekly
- Extreme
- An average of 14 or more episodes of inappropriate compensatory behaviors weekly
- References
- (2013) DSM V, APA, Washington
- Associated Conditions
- Female Athlete Triad
- Oligomenorrhea (50% of cases)
- No associated bone loss (contrast with Anorexia)
- Weight bearing Exercise protective of bone in Bulimia
- Psychiatric illness
- See Anorexia
- Personality Disorder (confers worse prognosis)
- Cluster B - dramatic, erratic
- Borderline Personality Disorder
- Narcissistic Personality Disorder
- Antisocial Personality Disorder
- Self deprecation and low self esteem
- Major Depression with suicidal ruminations
- Anxiety Disorder
- Risk-taking behaviors
- Substance Abuse
- Unprotected sexual activity
- Self mutilation
- Differential Diagnosis
- See Anorexia
- Labs
- Complete Blood Count
- Leukopenia
- Comprehensive Metabolic Panel (changes related to purging)
- Hypochloremic Metabolic Alkalosis
- Hypokalemia
- Serum Amylase
- May be increased with induced Vomiting
- Serum Lipase is often normal
- Humphries (1987) Ann Intern Med 106(1):50-2 +PMID:2431640 [PubMed]
- Serum Phosphorus
- Serum Magnesium
- Thyroid Stimulating Hormone
- Urinalysis
- Increased Urine Specific Gravity
- Increased Urine Ketones
- Decreased Urine pH
- Diagnostics: Electrocardiogram
- Same as in Anorexia
- Management: Inpatient Indications
- Suicidal Ideation with plan
- Intractable Vomiting
- Hematemesis
- Mallory-Weiss Tear (Esophageal Tear)
- Syncope
- Prolonged QTc or Cardiac Arrhythmia
- Serum Potassium <3.2 mg/dl
- Serum Chloride <88 mg/dl
- Hypothermia
- Failed outpatient management
- References
- Campbell (2014) Pediatrics 134(3): 582-92 [PubMed]
- Management: General
- Hypokalemia management if present
- Prevention of secondary complications
- Fluoridated Mouthwash and Toothpaste
- Sour candy to decrease Salivary Gland swelling
- Antacid medications for Reflux Esophagitis
- Management: Psychiatric
- Cognitive behavior therapy
- Cognitive behavior therapy is first line management
- Effective in only 40 to 50% of bulimic patients
- Indications to consider alternative therapy
- Purging not reduced 70% by sixth session
- Antidepressant agents are effective adjuncts to therapy
- Effexor
- Serzone
- Fluoxetine (titrate to 60 mg daily)
- Other Selective Serotonin Reuptake Inhibitors (SSRI)
- Avoid Wellbutrin (due to Seizure risk)
- Management: Oligomenorrhea
- History and physical examination
- Consistent with Anovulation
- Laboratory evaluation for significant Oligomenorrhea
- Urine Pregnancy Test
- Luteinizing hormone (LH)
- Follicle Stimulating Hormone (FSH)
- Thyroid Stimulating Hormone (TSH)
- Prolactin
- Total Testosterone and Free Testosterone
- Consider Serum Dehydroepiandrosterone sulfate level
- Indicated for signs of androgenization
- Suspected Unopposed Estrogen management
- Patient characteristics
- Normal weight patient
- Anovulation
- Elevated androgen levels
- Withdrawal bleed after Provera 10 mg x7 days trial
- Protocol for Endometrial Cancer prevention
- Provera 10 mg qd for 7 days repeated q3 months or
- Oral Contraceptive cycling
- Prognosis
- Remission rate with treatment: 80%
- Relapse rate: 20%
- All-cause mortality relative ratio: 1.6-1.9
- Resources
- Jackson (1991) Dieting: Dry Drunk- Dieting Recovery
- References
- (1994) DSM IV, APA, p. 544-5
- Agras (2000) Am J Psychiatry 157:1302-8 [PubMed]
- Harrington (2014) Am Fam Physician 91(1): 46-52 [PubMed]
- Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]
- McGilley (1998) Am Fam Physician, 57(11): 2743-50 [PubMed]
- Mehler (2003) N Engl J Med 349:875-81 [PubMed]
- Seidenfeld (2001) Am Fam Physician 64(3):445-50 [PubMed]
- Sundgot-Borgen (1998) J Clin Endocrinol Metab 83:3144-9 [PubMed]
- Walsh (2004) Am J Psychiatry 161:556-61 [PubMed]
- Yanovski (1991) Am Fam Physician, 44(4): 1231-38 [PubMed]