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Thursday, January 22, 2009

BULIMIA NERVOSA

BULIMIA NERVOSA - Jeffrey L. Goodie, PhD; Pamela Williams, MD
BASICS
DESCRIPTION
• A pattern of uncontrolled eating during discrete periods followed by compensatory behaviors.
• System(s) Affected: Oropharyngeal, Endocrine/Metabolic, Gastrointestinal, Dermatologic, Cardiovascular, Nervous
GENERAL PREVENTION
• Encourage realistic weight management strategies and attitudes
• Moderate overly high self-expectations
• Decrease anxiety/depressive symptoms
• Improve stress management
EPIDEMIOLOGY
• Predominant age: Adolescents and young adults; mean age of onset: 18-19
• Predominant sex: Female > Male (10:1 to 20:1)
Incidence
28.8 women, 0.8 men per 100,000 per year
Prevalence
• 1-2% in women 16-35 years old
• 0.1% in young 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; achievement pressure; competition stressors
• Low self-esteem
• Perceived pressure to be thin
• Perfectionistic or obsessional thinking
• History of anorexia nervosa
• Environment that stresses thinness or physical fitness (e.g., armed forces, ballet, cheerleaders, gymnastics, or models)
• Family history of substance abuse, affective disorders, eating disorder, or obesity
• Type I diabetes
• Poor impulse control, alcohol misuse
• Sexual abuse is not causally related to bulimia.
ETIOLOGY
Combination of biological, genetic psychological, environmental, and social factors. Unique contribution of any specific factor remains unclear.
ASSOCIATED CONDITIONS
• Major depression and dysthymia
• Anxiety disorders
• Substance abuse/dependence
• Bipolar disorder
• Obsessive-compulsive disorder
• Schizophrenic disorder
• Borderline personality disorder

DIAGNOSIS
DSM IV TR criteria
• Recurrent episodes of binge eating (2 times per week for 3 months)
- Eating in a discrete period of time more than most people would eat during that time
- Perceived lack of control during binge
• 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.
SIGNS AND SYMPTOMS
• 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
 Average binge between 1,000-2,000 kcals2
- Vomiting (often with little effort)
- Vigorous aerobic exercise
- Distress/shame related to loss of control
• Requesting weight loss help
• Menstrual disturbance
• Fatigue and lethargy
• Abdominal pain, bloating, constipation, diarrhea, irritable bowel syndrome, rectal prolapse
• Enamel erosion, parotid swelling, sore throat
• Onset may be stress related
• Mildly underweight to overweight
• Frequent fluctuations in weight
• Diet pill, diuretic, laxative, ipecac, and thyroid medication use/abuse
• Omission/underdosing insulin in diabetes patients
• Depressed mood and self-depreciation following the binges
• Relief and increased ability to concentrate following the purges
History
Corroborate with parent/relative
Physical Exam
• Often normal
• Eroded tooth enamel
• Asymptomatic, non-inflammatory salivary gland (parotid) enlargement
• Calluses, abrasions, bruising on hand, thumb
• Peripheral edema
TESTS
Lab
• All results may be within normal limits and are not necessary for diagnosis.
• Hypokalemia, hypochloremia
• Hypomagnesemia, hyponatraemia, hypocalcaemia, hypophosphataemia
• Alkalosis
• Leukopenia
• Elevated blood urea nitrogen
• Elevated basal serum prolactin
• Mild elevation in serum amylase
Imaging
Not indicated
Diagnostic Procedures/Surgery
Psychological self-report screening
• 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) questionnaire
Pathological Findings
• Esophagitis
• Pseudo-Bartter syndrome
• Acute pancreatitis
• Cardiomyopathy and muscle weakness due to ipecac abuse
DIFFERENTIAL DIAGNOSIS
• Anorexia, binge eating/purging type
• Major depressive disorder
• Psychogenic vomiting
• Hypothalamic brain tumor
• Epileptic equivalent seizures
• Kleine-Levin syndrome
• Body dysmorphic disorder
• Borderline personality disorder
TREATMENT
GENERAL MEASURES
• Most patients can be treated as outpatients.
• Outpatient
- Build trust, increase motivation for change
- Assess psychological and nutritional status
- Consider evidence-based self-help program
- Cognitive behavioral therapy (1-3)[A]
 Involve patient in establishing target goals
 Use self-monitoring techniques of food intake, frequency of binges/purges, related antecedents, consequences, and thoughts
 Self-monitoring weight once per week along with emotional and thought reactions
 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
 Address calories, weight, and purging ruminations
 Challenge fear of loss of control
 Establish relapse prevention plan
- Gradual laxative withdrawal
- Interpersonal therapy (1,3)[C]
- Family therapy for adolescents
- Nutritional education, relaxation techniques
- After vomiting, avoid brushing teeth and consider using non-acidic mouthwash (1)
- Limiting acidic foods, beverages to meal time
• Inpatient
- If possible, admit to eating disorders unit
- Supervised meals and bathroom privileges
- Monitor weight and physical activity
- Monitor electrolytes
- See outpatient recommendations
- Gradually shift control to patients as they demonstrate responsibility
Diet
• Balanced diet, normal eating pattern
• Reintroduce feared foods
Activity
• Monitor excess activity
• Encourage enjoyable activities
MEDICATION (DRUGS)
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. (1)[B]
• Tricyclic antidepressants (amitriptyline, desipramine, and imipramine) and monoamine oxidase inhibitors: Phenelzine (Nardil) 60-90 mg/d have been shown to decrease binging and vomiting. (1,2)[C] Patients with atypical depression may respond to monoamine oxidase inhibitors and not SSRIs.
• Augment with buspirone (BuSpar) if desired. To prevent relapse, maintain antidepressant medication at full therapeutic dose for at least 1 year.
• Note: Misrepresentation and non-adherence may be more likely in this population.
• Contraindications: Hypersensitivity
• Precautions
- Serious toxicity following overdose is common.
- Patients may vomit medications.
• Significant possible interactions
- Monoamine Oxidase Inhibitor should not be combined with SSRI or tricyclic medication
- Lithium and tricyclic medication can be lethal when administered to hypokalemic patients.
Second Line
• Ondansetron (Zofran) 4-8 mg t.i.d. between meals can help prevent vomiting.
• Psyllium (Metamucil) preparations 1 tbs qhs with glass of water, can prevent constipation during laxative withdrawal.
FOLLOW-UP
DISPOSITION
Admission Criteria
Hospitalize if severe malnutrition, dehydration, electrolyte disturbances, cardiac dysrhythmia, uncontrolled binging and purging, psychiatric emergency, or failed outpatient treatment.
PROGNOSIS
• Following effective treatment
- 50% asymptomatic after 2-10 years, 30% remissions, relapses, or subclinical behaviors; 20% no significant change
• Untreated
- Likely to remain chronic/relapsing problem
• Greater weight fluctuations, other impulsive behaviors, and personality disorder diagnoses may predict poor prognosis.
COMPLICATIONS
• Suicide
• Drug and alcohol abuse
• Infarction and perforation of the stomach
- Gastric dilatation
- Mallory-Weiss tears
- Spontaneous pneumomediastinum
• Potassium depletion; cardiac arrhythmia; cardiac arrest
• Maternal and fetal problems if pregnant
- Binging/purging behaviors may change with pregnancy
PATIENT MONITORING
• Binge-purge activity, including antecedents and consequences
• Level of exercise activity
• Self-esteem, comfort with body and self
• Ruminations and depression
• Repeat any abnormal lab values weekly or monthly until stable
REFERENCES
1. 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 January 20, 2006.
2. Bacaltchuk J, Hay P, Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Sys Rev. 2001(4):CD003385.
3. Hay PJ, Bacaltchuk J. Psychotherapy for bulimia nervosa and binging. Cochrane Database Syst Rev. 2003(1):CD000562.
4. Fairburn CG, Harrison PJ. Eating disorders. Lancet. 2003;361:407-416.
5. Mehler, PS. Bulmia nervosa. N Engl J Med. 2003;349:875-881.
ADDITIONAL READING
McCabe RE, McFarlane TL, Olmstead MP. Overcoming bulimia: your comprehensive, step-by-step guide to recovery. 2003; Oakland, CA: New Harbinger.
MISCELLANEOUS
See also: Anorexia nervosa; Hyperkalemia; Laxative abuse; Salivary gland tumors


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