Bulimia Nervosa – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • A pattern of discrete periods of uncontrolled eating, followed by compensatory behaviors
  • System(s) affected: Oropharyngeal; Endocrine/Metabolic; Gastrointestinal; Dermatologic; Cardiovascular; Nervous

Epidemiology

  • Predominant age: Adolescents and young adults
  • Mean age of onset: 18–21 years
  • Predominant sex: Female > Male (10–20:1)

Incidence

28.8 women, 0.8 men per 100,000 per year

Prevalence

  • 1–3% in women 16–35 years old
  • 0.5% in young men (higher among gay and bisexual men)

Risk Factors

  • Female gender
  • History of obesity and dieting
  • Body dissatisfaction
  • Critical comments by family or others about weight, body shape, or eating
  • Severe life stressor
  • Low self-esteem
  • Perceived pressure to be thin
  • Perfectionist or obsessive thinking
  • Poor impulse control, alcohol misuse
  • History of anorexia nervosa (AN)
  • Environment stressing high achievement, competition, thinness, or physical fitness (e.g., armed forces, ballet, cheerleaders, gymnastics, or models)
  • Family history of substance abuse, affective disorders, eating disorder, or obesity
  • Early feeding problems
  • Low birth weight for gestational age
  • Hyporeactivity at birth
  • Type I diabetes
  • Sexual abuse is not causally related to bulimia.

General Prevention

  • Prevention programs can reduce risk factors and future onset of eating disorders (1)[C].
  • Target adolescents and young women 15 years or older.
  • Encourage realistic and healthy weight management strategies and attitudes.
  • Decrease body dissatisfaction.
  • Promote self-esteem.
  • Reduce focus on thin as ideal.
  • Moderate overly high self-expectations.
  • Decrease anxiety/depressive symptoms.
  • Improve stress management.

Etiology

Combination of biological, psychological, environmental, and social factors. Unique contribution of any specific factor remains unclear.

Commonly Associated Conditions

  • Major depression and dysthymia
  • Anxiety disorders
  • Substance abuse/dependence
  • Bipolar disorder
  • Obsessive-compulsive disorder
  • Borderline personality disorder
  • Schizophrenic disorder

Eating disorder, Bulimia nervosa, Diagnostic and Statistical Manual of Mental Disorders, Self-esteem, Binge eating, Eating, Anorexia nervosa, history of anorexia nervosa, body dissatisfaction, healthy weight management, history of obesity, low birth weight, body shape, stress management,

Diagnosis

DSM-IV-TR criteria:

  • Recurrent episodes of binge eating (2 times per week for 3 months):
    • Eating in a discrete period more than most people would eat during that time
    • Perceived lack of control during binges
  • Recurrent inappropriate compensatory behavior (2 times per week for 3 months)
  • Purging and nonpurging subtypes:
    • Purging: Often by self-induced vomiting, laxatives, diuretics
    • Nonpurging: Binges followed by sharply restricted diet and/or vigorous exercise
  • Body shape and weight significantly affect self-evaluation.
  • Does not occur during AN episodes
  • Psychological self-report screening tests:
    • Eating Attitudes Test
    • Eating Disorder Inventory
    • Eating Disorder Screen for Primary Care
    • Bulimia Test (revised)
    • Bulimia Investigatory Test Edinburgh
    • SCOFF (sick, control, one, fat, food)

History

  • Patients unlikely to self-identify binge eating or purging behaviors; corroborate with parent/relative
  • Unhappiness and/or preoccupation with weight and diet attempts
  • Pattern of restricting diet, binge eating, and purging behaviors:
    • Binge is context-specific; amount can vary
    • Vomiting (often with little effort)
    • Vigorous aerobic exercise
    • Distress/shame related to loss of control
  • Depressed mood and self-depreciation following the binges
  • Relief and increased ability to concentrate following the purges
  • Other possible signs and symptoms:
    • Requesting weight loss help and mildly underweight to overweight
    • Diet pill, diuretic, laxative, ipecac, and thyroid medication use/abuse
    • Menstrual disturbance
    • Fatigue and lethargy
    • Abdominal pain, bloating, constipation, diarrhea, rectal prolapse
    • Sore throat
    • Frequent fluctuations in weight
    • Omission/underdosing insulin in diabetes patients

Physical Exam

  • Often normal
  • Bradycardia
  • Eroded tooth enamel
  • Asymptomatic, noninflammatory parotid gland enlargement
  • Epigastric tenderness to palpation
  • Calluses, abrasions, bruising on hand, thumb
  • Peripheral edema

Diagnostic Tests & Interpretation

All lab results may be within normal limits and are not necessary for diagnosis.

Lab

  • Blood work:
    • Hypokalemia, hypochloremia
    • Hypomagnesemia, hyponatremia, hypocalcemia, hypophosphatasemia
    • Alkalosis
    • Elevated blood urea nitrogen
    • Hypoglycemia
  • Urinalysis:
    • Increased urine-specific gravity

Diagnostic Procedures/Surgery

Electrocardiogram:

  • Bradycardia or arrhythmias
  • Conduction defects
  • Depressed ST segment due to hypokalemia

Pathological Findings

  • Esophagitis
  • Acute pancreatitis
  • Cardiomyopathy and muscle weakness due to ipecac abuse
  • Delayed or arrested skeletal growth
  • Stress fracture
  • Irreversible dental erosions
  • Osteopenia/osteoporosis

Differential Diagnosis

  • Anorexia, binge eating/purging type
  • Major depressive disorder
  • Anxiety disorders
  • Psychogenic vomiting
  • Malabsorption
  • Addison disease
  • Celiac disease
  • Diabetes mellitus
  • Hyperthyroidism; hypothyroidism
  • Hyperpituitarism
  • Hypothalamic brain tumor
  • Kleine-Levin syndrome
  • Body dysmorphic disorder
  • Borderline personality disorder

Treatment

  • Cognitive behavioral therapy (CBT) should be considered as 1st-line treatment (2,3,4)[A].
  • Guided self-help therapies may be effective (3,4)[B].

Medication

First Line

  • Selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine (Prozac) at 60 mg, are effective in reducing symptoms with relatively few side effects. Higher doses than standard doses for depression are often needed (3,5,6)[B]:
    • Combination of medication and CBT has been shown to have added benefit over medication or therapy alone (6).
  • To prevent relapse, maintain antidepressant at full therapeutic dose for at least 1 year.
  • Bupropion not recommended due to its association with seizures in patients who purge.
  • Misrepresentation and nonadherence may be more likely in this population.
  • Precautions:
    • Serious toxicity following overdose is common.
    • Patients may vomit medications.

Second Line

  • Ondansetron (Zofran) 4–8 mg t.i.d. between meals can help prevent vomiting.
  • Psyllium (Metamucil) preparations, 1 tbs q.h.s. with glass of water, can prevent constipation during laxative withdrawal.

Additional Treatment

Most patients can be treated as outpatients.

General Measures

  • Psychotherapies should be employed as 1st-line treatments.
  • Multidisciplinary team:
    • Primary care physician, behavioral health provider, nutritionist
  • Build trust; increase motivation for change.
  • Assess psychological and nutritional status.
  • Consider evidence-based self-help program.
  • Cognitive behavioral therapy for bulimia nervosa (2,3,4,5)[A]:
    • 16–20 50-minute appointments
    • Involve patient in establishing goals.
    • Self-monitoring of food intake, frequency of binges/purges, related antecedents, consequences, thoughts, and emotions
    • Self-monitoring of weight once per week
    • Educate about ineffectiveness of purging for weight control and adverse outcomes.
    • Establish prescribed eating plan to develop regular eating habits; realistic weight goal.
    • Gradually introduce feared foods into diet.
    • Problem-solve how to cope with triggers.
    • Decrease ruminations about calories, weight, and purging.
    • Challenge fear of loss of control.
    • Establish relapse prevention plan.
    • Gradual laxative withdrawal
  • Interpersonal therapy (2,3)[B]:
    • May act more slowly than CBT
  • Transdiagnostic cognitive-behavioral therapy
  • Dialectical behavior therapy
  • Family therapy for adolescents
  • Nutritional education, relaxation techniques
  • Educate patient to brush teeth and use baking soda to rinse mouth after vomiting.

Issues for Referral

Patients with bulimia require a multidisciplinary team, including a primary care physician, behavioral health provider, and a nutritionist.

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Complementary and Alternative Medicine

Bright light therapy may help (3).

In-Patient Considerations

  • If possible, admit to a specialized eating disorders unit.
  • Supervised meals and bathroom privileges
  • Monitor weight and physical activity.
  • Monitor electrolytes.
  • Gradually shift control to patients as they demonstrate responsibility.

Admission Criteria

Hospitalize if severe malnutrition, dehydration, electrolyte disturbances, cardiac dysrhythmia, uncontrolled binging and purging, psychiatric emergency, or if outpatient treatment failed

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

  • Binge-purge activity, including antecedents and consequences
  • Level of exercise activity
  • Self-esteem, comfort with body and self
  • Ruminations and depressive symptoms
  • Repeat any abnormal lab values weekly or monthly until stable.

Diet

  • Balanced diet, normal eating pattern
  • Reintroduce feared foods.

Patient Education

The following books may be useful for guided self-help treatment programs:

  • Fairburn CG. Overcoming Binge Eating. New York, NY: Guilford Press; 1995.
  • McCabe RE, McFarlane TL, Olmstead MP. Overcoming Bulimia: Your Comprehensive, Step-by-Step Guide to Recovery. Oakland, CA: New Harbinger; 2003.

Prognosis

  • After effective cognitive behavioral treatment:
    • In the short-term, 50% of treated individuals do not meet criteria for diagnosis.
    • In the long-term (2–10 years), 70% may be asymptomatic.
    • Symptomatic individuals may demonstrate remissions, relapses, subclinical, or other eating-related behaviors.
  • Untreated:
    • Likely to remain chronic/relapsing problem
  • Greater weight fluctuations, other impulsive behaviors, and personality disorder diagnoses may predict poor prognosis.

Complications

  • Drug and alcohol abuse
  • Osteopenia/osteoporosis
  • Stress fracture
  • Gastric dilatation
  • Mallory-Weiss tears
  • Spontaneous pneumomediastinum
  • Potassium depletion; cardiac arrhythmia; cardiac arrest
  • Suicide

Pregnancy Considerations

  • Maternal and fetal problems if pregnant:
    • Binging/purging behaviors may persist, increase, or decrease with pregnancy.
    • Increased risk for preterm delivery, operative delivery, and infants with low birth weight, smaller head circumference, and/or microcephaly; should be managed as high risk

References

1. Stice E, Shaw H, Marti CN. A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol. 2007;3:207–31.

2. Hay PP, Bacaltchuk J, Stefano S, Kashyap P et al. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009;CD000562.

3. Shapiro JR, Berkman ND, Brownley KA, et al. Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40:321–36.

4. NICE. Eating disorders–core interventions in the treatment of anorexia nervosa, bulimia nervosa, and related eating disorders. NICE Clinical Guideline no 9. London: NICE, 2004: Available at: http://www.nice.org.uk. Accessed July 17, 2008.

5. Practice guideline for the treatment of patients with eating disorders, 3rd edition. American Psychiatric Association. Available at http://www.psych.org. Accessed February 22, 2007.

6. Bacaltchuk J, Hay P, Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Sys Rev. 2001(4):CD003385.

Additional Reading

McElroy SL, Guerdjikova AI, Martens B, et al. Role of antiepileptic drugs in the management of eating disorders. CNS Drugs. 2009;23:139–56.

Powers PS, Bruty H. Pharmacotherapy for eating disorders and obesity. Child Adolesc Psychiatr Clin N Am. 2009;18:175–87.

See Also (Topic, Algorithm, Electronic Media Element)

Anorexia Nervosa; Hyperkalemia; Laxative Abuse; Salivary Gland Tumors

Algorithm: Weight Loss

Codes

ICD9

307.51 Bulimia nervosa

Snomed

78004001 Bulimia nervosa (disorder)

Clinical Pearls

  • Particularly among young women with a risk factor, asking “Are you satisfied with your eating patterns?” and/or “Do you worry that you have lost control over how much you eat?” may help to screen for those with an eating problem. A brief, standardized screening measure (e.g., SCOFF, ESP, EAT) will help to identify those who may need a broader assessment.
  • Binging and purging behaviors can be seen in anorexia nervosa as well.
  • Consider using a stepped-care approach. Start with a guided self-help program using instructional aids, next begin cognitive behavioral therapy (e.g., 16–20 sessions over 4–5 months).
  • SSRIs, particularly fluoxetine (60 mg daily), may be helpful as a 1st step or as an adjunctive treatment.

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