Bulimia Nervosa Disease

BASICS

DESCRIPTION

Classified in purging and non-purging subtypes. Purging often by self-induced vomiting, laxatives, diuretics. Non-purging type consists of - binges followed by sharply restricted diet and/or vigorous exercise.

System(s) affected: Endocrine/Metabolic, Nervous, Gastrointestinal, Cardiovascular
Genetics: Genetic component
Incidence/Prevalence in USA: Approximately 2% of females; higher among university women. True incidence is not known as this is a secretive disease.
Predominant age: Adolescents and young adults
Predominant sex: Female > Male

SIGNS AND SYMPTOMS

Patients may switch back and forth between purging and non-purging bulimia
Onset may be stress related
May be average weight or even somewhat obese; most are slightly below average weight
Frequent fluctuations in weight
Deny that there is a problem
Gobble high calorie foods during binge
Preoccupation with weight control
Food collection and hoarding
Diet pill, diuretic, laxative, ipecac and thyroid medication abuse
Prefers vigorous exercise, especially running, aerobics
Diabetic patients often withhold insulin
Depressed mood and self-depreciation following the binges
Relief and increased ability to concentrate following the purges
Vomiting (may be effortless)
Abdominal pain
Parotid swelling
Eroded teeth
Scarred hands or abrasions on back of hands
Cardiomyopathy and muscle weakness due to ipecac abuse

CAUSES

Thought to be largely emotional. moderate genetic influence

RISK FACTORS

Depression, obsessionality, impulsivity
Low self-esteem
Achievement pressure; high self-expectations; social anxiety
Acceptance of the culturally condoned ideal of slimness
Ambivalence about dependence/independence
Stress due to multiple responsibilities, tight schedules, competition
Weight dissatisfaction; perceived overweight
Environment that stresses thinness or physical fitness (eg, armed forces)
Family history of substance abuse, obesity, depression

DIAGNOSIS

LABORATORY

All results may be within normal limits
Elevated BUN
Hypokalemia, hypochloremia
Hypomagnesemia
Elevated basal serum prolactin
Mild elevation serum amylase
Positive dexamethasone suppression test
Low CD4/CD8 ratio

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Eroded tooth enamel
Esophagitis, Mallory-Weiss tears
Asymptomatic, non-inflammatory parotid enlargement
Gastric dilatation
Infarction and perforation of the stomach

SPECIAL TESTS

ECG
Gastric motility
Thyroid, liver, renal function
Drug screen

IMAGING

Not indicated

DIAGNOSTIC PROCEDURES

Psychological screening: Eating Attitudes Test, BULIT, SCANS, EDI

TREATMENT

APPROPRIATE HEALTH CARE

Most patients can be treated as outpatients
Hospitalize if patient is suicidal; if there is lab or ECG evidence of marked electrolyte imbalance; marked dehydration; or if there has been no response to outpatient therapy

GENERAL MEASURES

Inpatient:
- If possible, admit to eating disorders unit or unit with structured eating disorders program
- Supervised meals and bathroom privileges
- No access to the bathroom for 2 hours after meals
- Monitor weight and physical activity
- Assess psychological state and nutritional status
- Identify precipitants to bingeing
- Develop alternatives to purging
- Monitor electrolytes
- Focal individual and cognitive behavioral therapy. Frequent visits by physician.
- Gradually shift control to patient as she demonstrates responsibility
Outpatient:
- Build trust, treatment alliance
- Assess psychological state and nutritional status
- Involve patient in establishing target goals
- Use self-monitoring techniques such as food diary
- Identify prodromal states, precipitants
- Address ruminations about calories, weight, purging
- Focus on overall well-being, developing gratifying relationships
- Challenge fear of loss of control
- Cognitive-behavioral therapy and interpersonal therapy
- Family therapy for adolescents
- Nutritional education, relaxation techniques, couples therapy, self-help group may also be helpful.

SURGICAL MEASURES

N/A

ACTIVITY

Monitor excess activity
Stress importance of playful, pleasurable activities

DIET

Goal is a balanced diet with adequate calories and a normal eating pattern
Reintroduce feared foods

PATIENT EDUCATION

Seriousness and consequences of bulimic behavior
Information on nutrition, metabolic balance
Tools for self monitoring when appropriate

FOLLOW UP

PREVENTION/AVOIDANCE

Encourage rational attitude about weight
Moderate overly high self-expectations
Enhance self-esteem
Diminish stress

POSSIBLE COMPLICATIONS

Suicide
Drug and alcohol abuse
Potassium depletion; cardiac arrhythmia; cardiac arrest

EXPECTED COURSE AND PROGNOSIS

Highly variable, tends to wax and wane
May spontaneously remit
Most patients continue to binge/purge, but do so less often
Patients who do not establish trust likely to drop out of therapy, be lost to follow-up
Those who stay in therapy tend to improve
Patients with personality disorders have a generally poor prognosis
30-50% relapse rate per year for several years
Impulsive patients may engage in stealing, suicide gestures, substance abuse, promiscuity

MISCELLANEOUS

ASSOCIATED CONDITIONS

Major depression and dysthymia
Bipolar disorder
Obsessive-compulsive disorder
Social phobia and other anxiety disorders
Schizophrenic disorder
Substance abuse disorder
Borderline personality disorder
Compulsive shoplifting (kleptomania)

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: Less frequently diagnosed in men or in older women

PREGNANCY

Poor nutritional status may affect fetus
Binge-purge may increase or decrease during pregnancy

OTHER NOTES

Anorexic patients may deal with the frustration of chronic food deprivation by converting to bulimia
High risk
- Ballet dancers, models, cheerleaders
- Athletes, especially runners, gymnasts, weight lifters, body builders, jockeys, divers, wrestlers, figure skaters, field hockey players
Sub-clinical eating disorders are common in university populations
Sexual abuse is not causally related to bulimia
Chronic, extreme hypokalemia can occur without physical symptoms

ABBREVIATIONS

MAO = monoamine oxidase
SRI = serotonin reuptake inhibitors
TCA = tricyclic antidepressant

Clinical Investigations

ROLE OF HOMOEOPATHY

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