Bulimia Nervosa

Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating 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 use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. These episodes occur at least twice weekly for at least 3 months. Patients 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.

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Overview

Definition

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating (consuming a larger-than-appropriate amount of food in a set period of time) accompanied by inappropriate compensatory behavior (purging).

Epidemiology

  • Lifetime prevalence: 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 and satiety suggest the involvement of serotonin and norepinephrine in the pathophysiology of bulimia.

Diagnosis

History

  • Diagnosis is clinical, based on specific criteria:
    • Recurrent episodic binge eating 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
      • Self-induced vomiting
      • Fasting
      • Excessive exercise
    • Excessive emphasis on body shape or weight
  • At least 2 episodes per week for 3 months
  • Binge eating and compensatory behavior 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 > 18.5 kg/m2
  • Easy fatigability 
  • Orthostatic hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Physical signs consistent with self-induced vomiting: 
    • Swelling 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
    • 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 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 (Russell sign)
  • 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
  • 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

Lab findings

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

  • Increased serum amylase due to parotid gland hypertrophy
  • 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), which occur due to vomiting and excessive renal loss of potassium
  • 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:
    • 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 reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs; e.g., fluoxetine) 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 inhibitors Monoamine oxidase inhibitors Monoamine oxidase inhibitors are a class of antidepressants that inhibit the activity of monoamine oxidase (MAO), thereby increasing the amount of monoamine neurotransmitters (particularly serotonin, norepinephrine, and dopamine). The increase of these neurotransmitters can help in alleviating the symptoms of depression. Monoamine Oxidase Inhibitors, and mood stabilizers
    • Bupropion 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 may be necessary in cases of:
    • Failure of outpatient treatment
    • Self-injuring behavior 
    • Increased risk of suicidal tendencies
    • Severe electrolyte or metabolic abnormality

Prognosis

  • Higher rates of remission 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 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 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 are usually underweight and reluctant to seek medical help. Treatment involves CBT with antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications 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 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.
  • Rumination disorder Rumination Disorder Rumination disorder is a behavioral disorder marked by repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is not due to a medical disorder (GERD or pyloric stenosis) or other eating disorders (avoidant/restrictive food intake disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa). 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 GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease). Treatment involves multiple CBT techniques, including biofeedback 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, 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 Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder that includes recurrent episodes of hypersomnia 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 with bulimia nervosa. 

References

  1. Kessler RC, et al. (2013). The prevalence and correlates of binge eating disorder Binge Eating Disorder Binge eating disorder is an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior. Episodes occur at least weekly for 3 consecutive months. There is a loss of control during the episodes of binging as well as distress after. 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 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 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

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