Achieve Mastery of Medical Concepts

Study for medical school and boards with Lecturio

Bulimia Nervosa

Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating Binge eating Binge eating is defined as consuming an amount of food in a specified amount of time (e.g., 1 hour) that greatly exceeds what most people would consume in that same amount of time. Binge Eating Disorder accompanied by inappropriate compensatory behaviors ( laxatives Laxatives Laxatives are medications used to promote defecation. Most often, laxatives are used to treat constipation or for bowel preparation for certain procedures. There are 4 main classes of laxatives: bulk-forming, stimulant, osmotic, and emollient. Laxatives or diuretics Diuretics Agents that promote the excretion of urine through their effects on kidney function. Heart Failure and Angina Medication use, self-induced vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia, fasting, or excessive exercise) to counteract the effects of binge eating Binge eating Binge eating is defined as consuming an amount of food in a specified amount of time (e.g., 1 hour) that greatly exceeds what most people would consume in that same amount of time. Binge Eating Disorder and prevent weight gain. These episodes occur at least twice weekly for at least 3 months. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have normal body weight (or are slightly overweight). Treatment consists of a combination of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and pharmacotherapy.

Last updated: 21 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating Binge eating Binge eating is defined as consuming an amount of food in a specified amount of time (e.g., 1 hour) that greatly exceeds what most people would consume in that same amount of time. Binge Eating Disorder (consuming a larger-than-appropriate amount of food in a set period of time) accompanied by inappropriate compensatory behavior Compensatory behavior Binge Eating Disorder (purging).

Epidemiology

  • Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 1%
  • Women aged 18–35 most commonly affected
  • More prevalent in women
  • Later onset in adolescence than in anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa

Pathophysiology

  • No consensus on pathophysiology
  • May be related to abnormal functioning of corticolimbic circuits (involved in appetite) 
  • Efficacy of antidepressants as well as established link between serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS and satiety suggest the involvement of serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS and norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS in the pathophysiology of bulimia.

Diagnosis

History

  • Diagnosis is clinical, based on specific criteria:
    • Recurrent episodic binge eating Binge eating Binge eating is defined as consuming an amount of food in a specified amount of time (e.g., 1 hour) that greatly exceeds what most people would consume in that same amount of time. Binge Eating Disorder followed by feelings of disgust and guilt
    • Recurrent inappropriate compensatory behaviors to prevent weight gain, including:
      • Use of laxatives Laxatives Laxatives are medications used to promote defecation. Most often, laxatives are used to treat constipation or for bowel preparation for certain procedures. There are 4 main classes of laxatives: bulk-forming, stimulant, osmotic, and emollient. Laxatives or diuretics Diuretics Agents that promote the excretion of urine through their effects on kidney function. Heart Failure and Angina Medication
      • Self-induced vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
      • Fasting
      • Excessive exercise
    • Excessive emphasis on body shape or weight
  • At least 2 episodes per week for 3 months
  • Binge eating Binge eating Binge eating is defined as consuming an amount of food in a specified amount of time (e.g., 1 hour) that greatly exceeds what most people would consume in that same amount of time. Binge Eating Disorder and compensatory behavior Compensatory behavior Binge Eating Disorder do not occur exclusively during episodes of anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa.

Physical exam

Specific exam findings can be suggestive of eating disorders:

  • BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity > 18.5 kg/m2
  • Easy fatigability 
  • Orthostatic hypotension Orthostatic hypotension A significant drop in blood pressure after assuming a standing position. Orthostatic hypotension is a finding, and defined as a 20-mm hg decrease in systolic pressure or a 10-mm hg decrease in diastolic pressure 3 minutes after the person has risen from supine to standing. Symptoms generally include dizziness, blurred vision, and syncope. Hypotension
  • Physical signs consistent with self-induced vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
    • Swelling Swelling Inflammation of the salivary glands Salivary glands The salivary glands are exocrine glands positioned in and around the oral cavity. These glands are responsible for secreting saliva into the mouth, which aids in digestion. There are 3 major paired salivary glands: the sublingual, submandibular, and parotid glands. Salivary Glands: Anatomy
    • Dental caries
    • Scars or calluses on the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy from contact with the teeth Teeth Normally, an adult has 32 teeth: 16 maxillary and 16 mandibular. These teeth are divided into 4 quadrants with 8 teeth each. Each quadrant consists of 2 incisors (dentes incisivi), 1 canine (dens caninus), 2 premolars (dentes premolares), and 3 molars (dentes molares). Teeth are composed of enamel, dentin, and dental cement. Teeth: Anatomy ( Russell sign Russell sign Anorexia Nervosa)
  • Dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration
  • Menstrual irregularities
  • Mallory-Weiss syndrome Mallory-Weiss Syndrome Mallory-Weiss syndrome (MWS) is defined by the presence of longitudinal mucosal lacerations in the distal esophagus and proximal stomach, which are usually associated with any action that provokes a sudden rise in intraluminal esophageal pressure, such as forceful or recurrent retching, vomiting, coughing, or straining. Mallory-Weiss Syndrome (Mallory-Weiss Tear)
  • Bloating Bloating Constipation
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
Effects of bulimia on different systems in the body

Illustration representing the effects of bulimia on different systems in the body

Image by Lecturio.

Lab findings

Though not diagnostic, certain lab findings are suggestive of bulimia: 

  • Increased serum amylase Amylase A group of amylolytic enzymes that cleave starch, glycogen, and related alpha-1, 4-glucans. Digestion and Absorption due to parotid gland Parotid gland The largest of the three pairs of salivary glands. They lie on the sides of the face immediately below and in front of the ear. Salivary Glands: Anatomy hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation
  • Electrolyte abnormalities ( hypokalemia Hypokalemia Hypokalemia is defined as plasma potassium (K+) concentration < 3.5 mEq/L. Homeostatic mechanisms maintain plasma concentration between 3.5-5.2 mEq/L despite marked variation in dietary intake. Hypokalemia can be due to renal losses, GI losses, transcellular shifts, or poor dietary intake. Hypokalemia, hypochloremia Hypochloremia Electrolytes), which occur due to vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia and excessive renal loss of potassium Potassium An element in the alkali group of metals with an atomic symbol k, atomic number 19, and atomic weight 39. 10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte that plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. Hyperkalemia
  • Metabolic alkalosis Metabolic alkalosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic alkalosis also occurs when there is an increased loss of acid, either renally or through the upper GI tract (e.g., vomiting), increased intake of HCO3-, or a reduced ability to secrete HCO3- when needed. Metabolic Alkalosis (due to recurrent acid loss in vomit)

Management

Management

The 1st-line treatment is a combination of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and pharmacotherapy. 

  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
    • The mainstay of treatment is CBT.
    • Goal is to normalize patient’s eating behavior and avoid destructive binge-eating episodes.
    • CBT alone results in better outcomes than medications alone.
  • Pharmacotherapy:
    • Selective serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake inhibitors ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants; e.g., fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants) are preferred.
    • Other options: tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants, monoamine oxidase Oxidase Neisseria inhibitors, and mood stabilizers
    • Bupropion Bupropion A propiophenone-derived antidepressant and antismoking agent that inhibits the uptake of dopamine. Other Antidepressants is contraindicated in bulimia nervosa (may induce seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures). 
  • Adjunct therapy:
    • Nutritional rehabilitation: need a nutritionist guide to help replace nutritional stores
  • Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium may be necessary in cases of:
    • Failure of outpatient treatment
    • Self-injuring behavior 
    • Increased risk of suicidal tendencies
    • Severe electrolyte or metabolic abnormality

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Higher rates of remission Remission A spontaneous diminution or abatement of a disease over time, without formal treatment. Cluster Headaches and recovery than in anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. Anorexia Nervosa
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with comorbid substance use generally have worse outcomes. 

Differential Diagnosis

  • Anorexia nervosa: an eating disorder characterized by intense fear of gaining weight, restricted dietary habits, and distorted body image. Patients affected by anorexia nervosa are usually underweight and reluctant to seek medical help. Treatment involves CBT with antidepressant medication as an adjunct. Extreme cases may require hospitalization.
  • Binge-eating disorder: an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior, resulting in fluctuating body weight. Episodes occur at least once a week for 3 months. Treatment consists of a combination of psychotherapy and pharmacotherapy.
  • Rumination disorder: repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out, and which is not due to a general medical condition (e.g., GERD). Treatment involves multiple CBT techniques, including biofeedback psychotherapy, as well as medication when appropriate (e.g., proton pump inhibitors).
  • Kleine-Levin syndrome (KLS): also known as “sleeping beauty syndrome,” a very rare sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disorder that includes recurrent episodes of hypersomnia Hypersomnia Disorders characterized by hypersomnolence during normal waking hours that may impair cognitive functioning. Subtypes include primary hypersomnia disorders (e.g., idiopathic hypersomnolence; narcolepsy; and kleine-levin syndrome) and secondary hypersomnia disorders where excessive somnolence can be attributed to a known cause (e.g., drug affect, mental disorders, and sleep apnea syndrome). Whipple’s Disease that presents with behavioral or cognitive abnormalities, including compulsive eating and hypersexuality. Ptients with KLS do not have a crippling fear of weight gain or place a great deal of self-worth on their body weight and shape, unlike patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with bulimia nervosa. 

References

  1. Kessler RC, et al. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry. 73(9), 904–914. https://pubmed.ncbi.nlm.nih.gov/23290497/
  2. Norris M., et al. (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord. 47(5), 495–499. https://pubmed.ncbi.nlm.nih.gov/24343807/
  3. Mitchell, JE, Crow S. (2006). Medical complications of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 19(4), 438–43. https://pubmed.ncbi.nlm.nih.gov/16721178/
  4. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 15, Feeding and Eating Disorders. Philadelphia, PA: Lippincott Williams and Wilkins. pp. 509–532.
  5. Westmoreland P. (2017). Feeding and eating disorders. Retrieved May 27, 2021, from https://doi.org/10.2310/im.13038
  6. Westmoreland P. (2018). Clinical management of feeding and eating disorders. Retrieved May 27, 2021, from https://doi.org/10.2310/im.13039

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details