Bulimia nervosa is a disorder that is characterized by binge eating and inappropriate compensatory behavior to control weight with potentially dangerous sequelae. It is essential to identify and diagnose this condition promptly and to treat the patient effectively while monitoring progress and potential medical complications. This activity describes the evaluation and management of bulimia nervosa and highlights the role of the interprofessional team in the care of patients with this condition. Show Objectives:
IntroductionBulimia nervosa is a condition that occurs most commonly in adolescent females, characterized by indulgence in binge-eating, and inappropriate compensatory behaviors to prevent weight gain.[1] The Diagnostic and Statistical Manual of Mental Disorders- 5th edition (DSM-V) defines the following diagnostic criteria for bulimia nervosa: Episodes of binge eating:
Binging episodes are followed by inappropriate compensatory behavior to prevent weight gain:
The episodes should occur at least once a week for three months to establish a diagnosis.[3] EtiologyThe precise etiology of bulimia nervosa is unclear but is likely multifactorial. The abnormalities in interoceptive function, particularly of the insula, may contribute to the binging behavior associated with this condition. A 2016 study indicated that patients with anorexia and bulimia nervosa have widespread abnormalities with diffuse alterations in white matter structural and useful connectivity, particularly within appetite-regulating and taste-reward pathways. Other studies have indicated a possible altered function of intrinsic functional brain architecture.[4] EpidemiologyBulimia nervosa can affect both sexes but disproportionately affects females. The median age of onset is around 12.4 years old. The estimated prevalence of bulimia nervosa in the United States is 0.9% among adolescents, 1.5% among the general population of women, and 0.5% among the general population of men. While the prevalence of bulimia nervosa is unestablished in developing countries, prevalence estimates from North America, Australia, and Europe range from 0.1% - 1.3% among males and 0.5% - 2.0% among females.[5] History and PhysicalA review of systems in patients with bulimia nervosa demonstrates sore throat, irregular menstruation, constipation, headache, fatigue, lethargy, abdominal pain, and bloating. When conducting a physical exam on a patient with diagnosed or suspected bulimia nervosa, obtain the height, weight, vital signs, and orthostatic blood pressures. It is also necessary to examine a patient’s skin, mouth, and abdomen. A neurological examination is essential to check for primary neurological causes of weight loss or vomiting before diagnosing bulimia nervosa.[6] Common physical exam signs associated with bulimia nervosa include hypotension, dry skin, parotid gland swelling, dental erosion, and calluses on the dorsal aspect of the hand (known as “Russel’s sign.”) Bulimia nervosa can also be associated with hair loss, edema, and epistaxis.[6] EvaluationA thorough evaluation of a patient with bulimia nervosa should include the following:[7]
Laboratory abnormalities associated with bulimia nervosa include hypokalemia (including hypokalemic hypochloremic metabolic alkalosis), hyponatremia, and transaminitis. Treatment / ManagementThe primary objective of treatment is a cessation of the binging and purging behavior.[7] Selective serotonin reuptake inhibitors such as fluoxetine, citalopram, and sertraline have shown to reduce symptoms of bulimia nervosa. Fluoxetine is the only FDA approved medication for bulimia nervosa. It appears that a higher dose (60 mg) is significantly better than a placebo in decreasing the frequency of binge and vomiting episodes.[8] Evidence for other medication classes to treat this condition is limited.[9] Trazodone has significantly reduced the frequency of binge-eating episodes when compared to placebo.[10] Monoamine oxidase inhibitors and tricyclic antidepressants are reserved for resistant cases due to their lethality and potential side effects. Bupropion should not be used in patients with bulimia nervosa because of the increased risk of epileptic episodes.[11] One of the antiepileptic medications, topiramate, has shown a reduction in binge episodes, but the side effects should be carefully monitored, especially weight loss and cognitive problems.[12] Clinical trials of cognitive-behavioral therapy and interpersonal psychotherapy have also demonstrated a benefit for patients with bulimia nervosa.[13] Patients with bulimia nervosa should be screened for suicidality and comorbid psychiatric illness as they are at higher risk of other mental diseases than the general population. Bulimia nervosa can lead to a variety of general medical complications, including metabolic alkalosis, dehydration, constipation, and cardiac arrhythmias. The most common cause of metabolic alkalosis in patients with bulimia nervosa is fluid volume depletion, for which saline administration is indicated in addition to the cessation of the purging behavior. For inpatients, consider intravascular administration; however, these patients require monitoring for signs of volume overload. The treatment for dehydration associated with bulimia nervosa is similar. In the uncommon cases of average or increased fluid volume with alkalemia in a patient with bulimia nervosa, intravenous saline has no role. Treatment for constipation associated with bulimia nervosa or with discontinuation of laxatives include adequate hydration, exercise, and dietary fiber. If laxatives are still needed, low doses of polyethylene glycol powder or lactulose may be used. For patients who experience severe or symptomatic cardiac complications of bulimia nervosa, which are generally caused by electrolyte derangements, consider obtaining a cardiology consult. Differential DiagnosisThe clinician should make a diagnosis of bulimia nervosa after excluding all other medical causes of vomiting and excessive bowel activity, particularly if the patient states that binging or purging behavior is involuntary. Generally, these medical conditions are not associated with a pattern of binge eating or an excessive preoccupation with weight or body image. These medical conditions include the following:
General medical conditions involving increased food intake include the following:
PrognosisMost patients who have bulimia nervosa will recover from the condition. The five-year remission rate for bulimia nervosa using DSM-IV criteria has an estimate of 74%, and among those, 47% also had a relapse within those five years. Another study based on DSM-V criteria listed a 55% five-year recovery rate for bulimia nervosa in the community. At ten years, 52% of patients with bulimia nervosa treated with placebo had fully recovered. Bulimia nervosa is proven to be associated with an increase in all-cause mortality.[14][15] ComplicationsBulimia nervosa is a psychiatric disorder that can lead to potentially critical complications. Unlike in anorexia nervosa, in which complications are due to weight loss and malnutrition, the type and severity of medical complications of bulimia nervosa can be determined based on the frequency and the method the patient uses to purge.[16] Complications associated with bulimia nervosa include the following:[7][17][18]
Deterrence and Patient EducationIt is important to educate patients who abuse laxatives that these medications work in the gastrointestinal tract after the areas where caloric absorption has occurred primarily. It is crucial to inform patients that a period of edema and weight gain may follow up to several weeks after discontinuation of purging behavior. Patients with bulimia nervosa who purge by vomiting often brush their teeth immediately after purging, which can accelerate dental erosion. The clinician should instruct the patients who persist in vomiting to rinse their mouths with water or fluoride rather than brushing their teeth within 30 minutes of each episode. Consider consulting a dentist to address dental issues associated with vomiting. Enhancing Healthcare Team OutcomesPatients with bulimia nervosa should undergo an initial medical evaluation to determine medical stability and whether the patient needs hospitalization. [Level 5] Patients with eating disorders, including bulimia nervosa, are best managed by an interprofessional team that includes a primary clinician, a therapist or psychiatrist, school personnel, a dietician, and an eating disorder specialist. [Level 5] Bulimia nervosa may be treated effectively with a selective serotonin reuptake inhibitor [Level 2] and psychotherapy, such as cognitive-behavioral therapy. [Level 2] References1.Harrington BC, Jimerson M, Haxton C, Jimerson DC. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician. 2015 Jan 01;91(1):46-52. [PubMed: 25591200] 2.Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med. 1979 Aug;9(3):429-48. [PubMed: 482466] 3.Forney KJ, Bodell LP, Haedt-Matt AA, Keel PK. Incremental validity of the episode size criterion in binge-eating definitions: An examination in women with purging syndromes. Int J Eat Disord. 2016 Jul;49(7):651-62. [PMC free article: PMC4942344] [PubMed: 26841103] 4.Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 01;61(3):348-58. [PMC free article: PMC1892232] [PubMed: 16815322] 5.Wu J, Lin Z, Liu Z, He H, Bai L, Lyu J. Secular trends in the incidence of eating disorders in China from 1990 to 2017: a joinpoint and age-period-cohort analysis. Psychol Med. 2022 Apr;52(5):946-956. [PubMed: 32744194] 6.Brown CA, Mehler PS. Medical complications of self-induced vomiting. Eat Disord. 2013;21(4):287-94. [PubMed: 23767670] 7.American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54. [PubMed: 16925191] 8.Fluoxetine in the treatment of bulimia nervosa. A multicenter, placebo-controlled, double-blind trial. Fluoxetine Bulimia Nervosa Collaborative Study Group. Arch Gen Psychiatry. 1992 Feb;49(2):139-47. [PubMed: 1550466] 9.Shapiro JR, Berkman ND, Brownley KA, Sedway JA, Lohr KN, Bulik CM. Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007 May;40(4):321-36. [PubMed: 17370288] 10.Pope HG, Keck PE, McElroy SL, Hudson JI. A placebo-controlled study of trazodone in bulimia nervosa. J Clin Psychopharmacol. 1989 Aug;9(4):254-9. [PubMed: 2671058] 11.Horne RL, Ferguson JM, Pope HG, Hudson JI, Lineberry CG, Ascher J, Cato A. Treatment of bulimia with bupropion: a multicenter controlled trial. J Clin Psychiatry. 1988 Jul;49(7):262-6. [PubMed: 3134343] 12.Nickel C, Tritt K, Muehlbacher M, Pedrosa Gil F, Mitterlehner FO, Kaplan P, Lahmann C, Leiberich PK, Krawczyk J, Kettler C, Rother WK, Loew TH, Nickel MK. Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial. Int J Eat Disord. 2005 Dec;38(4):295-300. [PubMed: 16231337] 13.Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders. Curr Opin Psychiatry. 2013 Nov;26(6):549-55. [PMC free article: PMC4096990] [PubMed: 24060917] 14.Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011 Jul;68(7):724-31. [PubMed: 21727255] 15.Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. Int J Eat Disord. 2014 Jul;47(5):507-15. [PubMed: 24599787] 16.Johnson JG, Spitzer RL, Williams JB. Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynaecology patients. Psychol Med. 2001 Nov;31(8):1455-66. [PubMed: 11722160] 17.Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med. 2016 Jan;129(1):30-7. [PubMed: 26169883] 18.Brown CA, Mehler PS. Successful "detoxing" from commonly utilized modes of purging in bulimia nervosa. Eat Disord. 2012;20(4):312-20. [PubMed: 22703572] 19.Forney KJ, Buchman-Schmitt JM, Keel PK, Frank GK. The medical complications associated with purging. Int J Eat Disord. 2016 Mar;49(3):249-59. [PMC free article: PMC4803618] [PubMed: 26876429] 20.Denholm M, Jankowski J. Gastroesophageal reflux disease and bulimia nervosa--a review of the literature. Dis Esophagus. 2011 Feb;24(2):79-85. [PubMed: 20659142] 21.Dessureault S, Coppola D, Weitzner M, Powers P, Karl RC. Barrett's esophagus and squamous cell carcinoma in a patient with psychogenic vomiting. Int J Gastrointest Cancer. 2002;32(1):57-61. [PubMed: 12630772] 22.Dejong H, Perkins S, Grover M, Schmidt U. The prevalence of irritable bowel syndrome in outpatients with bulimia nervosa. Int J Eat Disord. 2011 Nov;44(7):661-4. [PubMed: 21997430] |